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PLANNING FRAMEWORK 

FOR 

NAVY MEDICINE 




VERSION 1 1 
31 JAN 94 



TABLE OF CONTENTS 



OVERVIEW - WHY DO HEALTH CARE PLANNING? 05 

A. Introduction 05 

B. System-Wide Health Care Planning (Top Down) 05 

C. Catchment Area Health Care Planning (Bottom Up) 06 

D. Interface Between System-Wide and Catchment Area 

Health Care Planning 06 

E. Expected End-Products and Uses of the Catchment 

Area Health Care Planning Process 07 

F. Purpose of this Manual 08 

Steps in the Planning Process (TAB A) 

SECTION I - IDENTIFY THE ISSUE 10 

A. Introduction 10 

B. Getting Started - What's Needed to Do the Job 10 

1. Overview 10 

2. Do an Inventory 11 

3. Getting Organized 12 

4. Setting Realistic Goals 12 

5. Establishing a Baseline for Your Catchment Area 13 

C. Health Care Capabilities Assessment - What is the 

Environment Telling Us 13 

1. Internal Assessment 14 

2. External Assessment 15 

3. Assess the Health Care Capabilities of the 

Other (Non-Navy) Sources 16 

4. Snapshot Of How Health Care Is Being Delivered 

RIGHT NOW 17 

5. Anticipated Changes 19 

Internal & External Assessment (INVENTORY A^ (TAB B) 

Naw Hospital Resources (INVENTORY B) (TAB C) 

PART 1 - Facilities 34 

PART 2 - Ancillary Services 36 

PART 3 - Manpower/Personnel 38 

PART 4 - Training 39 

PART 5 - Branch Clinics 40 



25 Jan 94 



TABLE OF CONTENTS (continued^ 



D. Planning Considerations - Measures Of Effectiveness (MOE's) 43 

1. Readiness 43 

2. Quality 44 

3. Satisfaction 44 

4. Resource Management 44 



III. SECTION II - SPECIFY THE POPULATION 45 

A. Introduction 45 

B. Military Beneficiary Population Estimates & Projections 46 

1 . Report 1 - Population Projections for Catchment Area 47 

C. Optional Reports 48 

2. Report 2 - RAPS Service Area Report 48 

3. Report 3 - State/Country Report 48 

D. Naval Medical Clinics 49 

E. Population by Zip Code 49 

F. RAPS Limitations and Efforts to Improve 49 

G. Civilian Population Estimates 50 

H. Reporting Requirements 52 

Population Projection Report Examples {TAB D) 



IV. SECTION III - ASSESS NEED 56 

A. Introduction 56 

B. Example 56 

C. "Needs" Ongoing Tool Development 57 

D. Retrospective Case Mix Analysis System (RCMAS) Norms and Expectancy 

Rates 57 

V. SECTION IV - ASSESS DEMAND - UTILIZATION ANALYSIS 58 

A. Introduction 58 

B. Historical Demand and Current Utilization 58 

C. Direct Care and CHAMPUS Workload Data 59 

D. Historical Utilization 60 



25 Jan 94 



TABLE OF CONTENTS (continued^ 



E. Current Utilization Data 60 

1. Inpatient Report 62 

.2. Outpatient Report 62 

3. Non-Availability Report 62 

4. Out-Catchment Area Report 62 

F. Patient Migration and Referral 63 

G. Utilization Analysis and Evaluation of Health Care Outcomes 65 

H. Customer Expectations and Surveys 66 

I. Utilization Analysis Summary 66 

MCQA Utilization Report Examples (TAB E) 



VI. SECTION V - DETERMINING REQUIREMENTS FOR SERVICE 71 

A. Introduction 71 

B. Compatibility of CHAMPUS, MEPRS and RAPS 71 

C. RAPS Utilization Projection Reports 72 

1 . Report 1 - Inpatient Direct Care 72 

2. Report 2 - Inpatient Non-Direct Care 72 

3. Report 3 - Outpatient Direct Care 72 

4. Report 4 - Outpatient Non-Direct Care 72 

D. Analysis .74 

E. Utilization Rates/Trade-Off Factors 74 

F. Comparisons - Actual verses RAPS Expected Utilization 75 

G. Joint Healthcare Manpower Standards (JHMS) DoD 6025.12-STD 75 

H. New Ways of Doing Business 77 

RAPS Utilization Report Examples (Projections 1 ) (TAB F) 



VII. SECTION VI - FORECAST RESOURCE REQUIREMENTS 82 

A. Introduction 82 

B. Allocation of Resources between Direct Care System and other 
Alternative Sources of Care 82 

C. MEPRS Cost Allocation Compared with the Civilian Sector 83 

D. Inpatient/Outpatient Costing Methodology 83 

E. Executive Information System (EIS) Financial Module 83 

F. Retrospective Case-Mix Analysis System 84 



25 Jan 94 



TABLE OF CONTENTS (continued) 



G. RAPS 84 

1 . Report 1 - Inpatient Direct Care Costs 85 

2. Report 2 - Inpatient Non-Direct Care Costs 85 

3. Report 3 - Outpatient Direct Care Costs 85 

4. Report 4 - Outpatient Non-Direct Care Costs 85 



H. Make Buy Cost Analysis 86 

I. Capitation Budgeting 86 

J. Other Data Sources 88 

K. Summary 88 

RAPS Cost Report Examples (TAB G) 



VIII. SECTION VII - BEGIN PLAN DEVELOPMENT 95 

A. Introduction 95 

B. Current Initiatives and System-Wide Balancing & Optimization 95 

IX. SECTION VIII - DEVELOP ALTERNATIVE DELIVERY STRATEGIES 97 

A. Introduction 97 

B. Business Plans 97 



List of Health Care Planners Enclosure (1) 

List of Major Data Sources/Bases Enclosure (2) 

"Needs" Overview Enclosure (3) 

Primary Care Model Enclosure (4) 

Health Maintenance Organizational Model Enclosure (5) 



25 Jan 94 



OVERVIEW I - WHY DO HEALTH CARE PLANNING? 

A. INTRODUCTION . Health care planning is not a "new" discipline or a "new" 
focus for the Navy. Most of you learned the basic process as part of your 
baccalaureate and masters degree course work. The vast majority of you have always 
used a logical method for determining what health care services were needed by your 
beneficiary population and how best to provide those services. Both catchment area 
and BUMED planners identified one basic problem with health care planning in the 
Navy, we don't all use the same framework, data, methods. This has become a real 
problem, especially with the implementation of coordinated/managed care. Many of 
you have been asking for a "how-to" type of manual. In addition, headquarters 
planners need to have everyone using the same framework, data, and methods so 
they can make system-wide comparisons and impact analyses. That's how the idea 
for this manual was born. What we hope you will find is a standardized framework 
which uses standardized data sources and methods, yet which incorporates the 
capability for inclusion of and customizing for locally-unique factors. 

Coordinated/managed care requires a systematic approach to planning for health 
care delivery to our beneficiaries. We know we probably cannot provide all the 
required health care services at our own MTF or clinics so we need to know what 
other options are "out there" for our customers. CHAMPUS? PPOs? Should we 
consider a cooperative arrangement with the Air Force hospital for lab work or x-rays? 
Could the local VA hospital help out with acute care if we do their CAT scans? What 
will happen if the Army hospital closes - how many people will we have to add to our 
service area population, and what services will they require? Would our customers 
prefer a Saturday hypertension clinic? Which provider type would most women prefer 
to do their GYN exams and PAP smears? What type of services should we be 
providing to assist our active duty to maintain their level of health and readiness for 
war? What is more cost-effective: cleaning the linen inhouse or contracting for it or 
arranging a "swap" with the VA for a service they need? Catchment area health care 
planners can bring everything into focus, with a logical, standardized approach to 
health care delivery which will benefit all our customers and providers. 

B. SYSTEM-WIDE HEALTH CARE PLANNING (TOP DOWNV Health care 
planners at BUMED are constantly looking at ways to optimize the system. The goal 
is to make our system as effective and functional as possible, balancing the health 
care requirements of our beneficiaries with the realities of resource constraints. 
Optimizing the system seldom means optimizing every sub-unit (MTF) of the system. 
This means BUMED planners need to know your requirements but will not be able to 
please everyone. The Health Care Planning Process presented in this manual will also 
be used by BUMED planners. Their concerns are more global and "macro" than 
catchment area planners. For example, they will seek solutions to a[l base closures, 
a[l homeporting changes, all fluctuations in contracting dollars. They will determine the 
most appropriate placement for ever-decreasing military billets and civilian positions. 

25 Jan 94 5 



C. CATCHMENT AREA HEALTH CARE PLANNING (BOTTOM UPl If you are 
reading this manual, you already are probably doing health care planning for your 
catchment area. Coordinated/managed care requires that the scope of your health 
care planning extend beyond the confines of your hospital and its clinics. Accordingly, 
this manual will refer to you as a "catchment area" planner. Even if your MTF is not 
scheduled for implementation of coordinated care this year, catchment area planning 
makes good sense. Navy Medicine is no longer in a "growth mode". We have to find 
innovative, creative, and workable solutions to the problem of delivery of health care 
services to our beneficiaries. It is critical that we get out of the "seat of our pants" 
mode of operations and rationalize what we do, and why we do it. Congress is 
insisting on data and analysis in support of all our policy decisions, and our customers 
deserve the very best we can provide. Previously, we didn't have to put a price tag on 
what we did - we just did it, and let someone else worry about the bill. As you know, 
those days are over. This may be a major change of focus for some people who still 
believe that only Navy personnel should provide health care to our beneficiaries 
because no one else can do it as well. This is naive thinking. We have demonstrated 
that civil service, contract, and partnership personnel can be important members of 
the Navy health care family. We are not going to gain more active duty billets in the 
foreseeable future. It makes sense for planners to pro-actively examine a[l possibilities 
so we can continue to offer the same quality and quantity of health care services. 

Planners need to determine just what health care services our customers require 
and the most effective and efficient way to provide access to those services. In the 
near future, we may not be able to provide all the required services inhouse, except in 
isolated or OCONUS locations. The goal will be to provide inhouse the services that 
we are able to provide more effectively (e.g. flight line stand-by's) and/or more 
economically than other alternatives. The challenge will then be to find cost-effective 
ways to provide convenient and effective access to other alternatives for the other 
required services. 



D. INTERFACE BETWEEN SYSTEM-WIDE & CATCHMENT AREA HEALTH CARE 
PLANNING . Naval health care planning has to be bottom-up and top-down. 
Catchment area planners need information about policies and the Big Picture from 
system-wide planners. System-wide planners need information about customer 
expectations, MTF capabilities, and viable health care alternatives from catchment area 
planners. Using a common framework, both sets of planners can work more 
effectively as a team to estimate requirements for services, distribute scarce resources, 
and evaluate alternatives. Health care planning for the catchment area is best done at 
the catchment area level, with BUMED assistance and guidance. System-wide 
planning will become more effective as BUMED planners gain more information and 
understanding of the realities and capabilities of each catchment area. 



25 Jan 94 



E EXPECTED END-PRODUCTS & USES OF THE CATCHMENT AREA HEALTH 
CARE PLANNING PROCESS . Several types of data are essential for effective 
planning. These include demographic information about various segments of the 
population served; detailed information about clinical services capabilities inhouse and 
within the catchment area; and environmental trends within the catchment area, Navy, 
and health care system. The standardized planning process is expected to enable 
catchment area health care planners to obtain, organize, and update baseline 
information about their hospital and clinics, and their catchment area. Some of the 
requirements of our customers can only be accomplished with Blue Suit (Navy) health 
care providers. Operational units, for example, on ships, with air squadrons, attached 
to Marine units, are clear examples of situations where a uniformed physician, nurse, 
or corpsmen cannot be substituted with a civilian provider. One of the new challenges 
facing Navy health care planners is to determine the actual Blue Suit requirements. 
What is so Navy-unique about the service provided, or the setting in which it is 
provided, that only a uniformed person can do the job? The standardized planning 
process is expected to enable catchment area health care planners to determine the 
"real" Blue Suit requirement, using criteria furnished by BUMED. In the past, the Navy 
uses historical workload data for planning and for forecasting utilization of services. 
However, health care use behavior is more complex. People have specific needs for 
services. These are determined by the community and/or clinicians. People also 
have specific desires, wants, expectations for health care services. People also 
engage in specific behaviors, i.e. show up for sick call, phone for appointments. 
Finally, we as a health care delivery system, provide specific services to those who 
seek health care. What is the "real" requirement for services? The standardized 
planning process is expected to enable catchment area health care planners to 
estimate the health care services requirement for the current and projected population. 

Make/buy decision-making is an vital component of health care planning as well 
as for management of coordinated/managed care operations. Accurate and current 
data are essential for making informed and optimal make/buy decisions. The 
standardized planning process is expected to enable catchment area health care 
planners to have the necessary data and methods for accomplishing make/buy 
operations. Those of you who are Navy health care planners have an exciting 
challenge ahead. You will be pioneers into new territory, frightening to some, 
exhilarating to others. Coordinated/managed care will break many of the old 
paradigms about how we do business, but at the end of the process, we expect to 
have a more efficient and effective way to meet the requirements of our customers. 
The standardized planning process is expected to provide catchment area health care 
planners with a framework for accomplishing the various components of 
coordinated/managed care. 



25 Jan 94 



F. PURPOSE OF THIS MANUAL This manual is designed to give you, the 
catchment area planner, the information you need to do your job. We want you to let 
us know if it accomplishes that goal, and if not, what tools or methods we need to add 
to the manual. We don't expect to have designed the perfect manual right now. Even 
as you read this, policy planners throughout DoD are working to perfect better data 
collection methods, better databases, better technology, better ways to evaluate 
options. Policy-makers continue to define the benefit, determine Blue Suit 
requirements, estimate draw-down impacts, examine health care delivery options, 
evaluate GME, etc. Therefore, we would like you to view this manual as a set of 
modules. As we get better at something, we'll just pull out the old module, and 
replace it with the new and improved module. In this way, this manual will never 
become outdated or lose its usefulness. We look forward to all your suggestions. 



25 Jan 94 8 



TAB A - STEPS IN THE PLANNING PROCESS 

The planning process has a number of steps which are outlined below and 
discussed in detail in subsequent section of this document. As you will read, some 
steps are better defined in terms of tools, data source, and future developments. Our 
purpose is to take the best of what is currently available and to modify sections in the 
process as new more update material presents itself. Therefore, updates and 
reassessments will be mad on a continuous basis. Your initial response and 
evaluation of this document will provide a basis for continued improvement. 

STEP 1 - Identify the Planning Issue. The planning issue may be very broad or very 
specific. When identifying the issue there should be an understanding of its 
relationship with other broader, more defined issues, an identification of possible 
trade-offs involved, and any known constraints. 

STEP 2 - Specify the Population. This process involves identifying the current and 
future demographic characteristics of the population affected by the planning issue. 

STEP 3 - Assess the Demand. This step analyses the historical utilization of 
services by population under consideration and taking into account the effects of 
future changes in the population. 

STEP 4 - Assess the Need. This deals with looking at what services a given 
population should be receiving as opposed to what they have received. 

STEP 5 - Determine Requirements for Services. This is a synthesis of Steps 3 and 4 
to translate Demand and Need into overall requirements necessary to provide the 
required services. Our analysis so far deals primarily with overall manpower 
requirements needed to provide the service. 

STEP 6 - Forecast Resource Requirements. This deals with costing issues and 
make-buy analysis to determine the best mix of direct care and alternative ways of 
delivering health care, 

STEP 7 - Develop a Business Plan. Based upon the alternatives developed in 
previous steps in addition to guidance provided by BUMED, the MTF will be in a 
position to develop a Business plan for provision of services. A detailed Business 
Plan for how you determine health care should be delivered in your catchment area 
will be developed accordingly. 

STEP 8 - Develop Alternative Delivery Strategies. To be individually carried out at 
each MTF. 



25 Jan 94 9 



SECTION I - IDENTIFY THE ISSUE 

A. INTRODUCTION . The first stage in the planning process is to identify the 
planning issue, in this case, the planning issue is how to determine catchment area 
health care resource requirements in sufficient detail to support MTF business 
planning and BUMED policy planning. This broad level of planning should allow the 
MTFs to look at health care delivery dynamics throughout the catchment area, across 
medical specialties and across beneficiary categories. It should provide the MTF 
commander and BUMED with a clearer picture of the health care priorities and issues. 

B. GETTING STARTED - WHAT'S NEEDED TO DO THE JOB? Health care 
planning is not a "seat of your pants", collateral duty type of assignment. It is a 
professional specialty and has a unique body of knowledge, including established 
theory and scholarly research. The concepts and methodologies are derived from a 
multi-disciplinary base, including economics, demography, epidemiology, health 
services research, business administration, medical sociology, and statistical analysis 
and methods. Many of the methods used today were initiated in the civilian sector 
during the mid-1970s, with Certificate of Need legislation requirements for regional 
health care planning. Successful planners are curious, analytical, and tenacious. 
They are innovative and creative, but always realists. This manual will help you to start 
thinking like a planner and give you much of the information you need to get started. 
Pick up your old textbooks. Planning should be fun and exciting most of the time. 
Once you get going, hopefully you will agree. 

1 . OVERVIEW . Data are everywhere and you need as much as possible to be 
an effective planner. You will be using formal sources of data, including Department of 
Defense or Navy standardized databases (for example, RAPS, RCMAS, CHCS, 
MEPRS). Equally important, however, are the informal sources of data you learn 
everyday - "Chevrolet just decreased health benefits to their white collar workers. 
Congress just approved a new Veterans Administration hospital to be located in your 
catchment area. The local school system just mandated that students receive a brand 
new immunization. One of the line commands you serve is being totally 
disestablished. Five obstetricians and three nurse midwives have just moved into your 
catchment area. A new nursing school just opened down the street. One of your 
operating rooms needs major structural repairs. The Air Force hospital's laboratory 
had to restrict operations due to an AIDs scare" - and so on. But how much is too 
much? The short answer is that at one point a planner needs to say, "that's it" and 
make a decision or a plan based on the best information available at the time. The 
long answer is that no decision is final, we are constantly making better decisions 
because of better and more complete information, and the planning process is 
iterative. One of the characteristics of planning is that it is iterative. "Iterative" means 
that the replication of a cycle of operations (the planning process) produces results (a 
plan or decision) which approximate the desired (best plan or best decision) more and 
more closely. 

25 Jan 94 10 



Equipment requirements for planning can range from pencil and paper to highly 
advanced computers. Better equipment will not ensure that you will be a top-notch 
planner, but certain items are required for the job. You will need a personal computer, 
a modem, and a printer. Commercial computer software packages for word 
processing and spreadsheet preparation, such as WordPerfect and Lotus 1-2-3, are 
also necessary. Initially, you may need to be inventive, borrow, and/or share with 
others. Not everyone can or should have the most powerful computer, software, or 
statistical packages. Most of you will start with very basic equipment and software. 
The decision to purchase advanced computer systems and software - like any 
planning decision - will require your commanding officer to evaluate an analysis of 
cost/benefits, and command long-range objectives. Certainly, as our planning 
methodologies evolve, a vintage 1984 IBM probably won't do the job anymore. 
However, the purchase of a $5000.00 statistical software package to be used 
exclusively at a branch clinic most likely will not be appropriate for a long time. 

2. DO AN INVENTORY . A major part of your job as a planner will be to seek 
out information. Your first challenge will be to find out what is available right now that 
will enable you to get started. The first thing you have is this manual and BUMED's 
commitment to assist and advise. The important phone numbers in MED-08 are (202) 
653-0223/0230, or DSN 294-0223/0230. Second, don't be shy about calling any of 
the planners listed in Enclosure (1). These are folks who have been doing health care 
planning for a few years and have probably experienced all the challenges you are 
about to encounter. Next, do an inventory of the people, equipment, software, 
databases, and other sources of information at your hospital and clinics. Has anyone 
ever done health care planning? Do you have a POMI specialist onboard? Does your 
hospital library have any health care administration and planning texts? What 
professional management journals are received by the command and how can you get 
on the distribution list? is there a budget item for books or professional journals and 
how can you have input into the selection process? What computer hardware and 
software already exists at your hospital and clinics? Who owns it and would they be 
willing to let someone else use it part of the day? Is there a budget item for software 
and how can you have input into the selection process? What databases exist at the 
command? Are the data elements relevant to health care planning? Is it possible for 
you to gain access to the data? What are other sources of data maintained at the 
command which would be useful for planning? Could those data easily be entered 
into a database? Will you have a full or part-time staff and what will be their 
capabilities? If not, is there someone who could be available for a few hours a week 
to assist you? Finally, do an inventory of the people and data sources available in 
your catchment area. Do you have a local Veterans Administration, Army, or Air Force 
medical treatment facility? Do they have a planner? Do they have databases 
(standardized or informal) which you could access? Do they or the local university 
have textbooks and/or professional journals which you could use? Does the local 
university have business or health care administration department with whom you 
could discuss health care planning? 

25 Jan 94 11 



3. GETTING ORGANIZED . Some of you may already be doing planning on a 
full-time basis, as a designated organizational entity with a permanent staff and 
appropriate equipment, supplies and space. For those who are just starting up a 
formal planning function, here are some ideas about getting started. The health care 
planner should be designated as such and be assigned full-time to the job. 
Organizationally, you could effectively work directly either for the Executive Officer or 
the Director for Administration. At the present time, your organizational placement will 
be a command decision, based on what is most appropriate for your command 
functioning. You should have a separate place to work, but if an office is not available, 
at least space that is only for you and planning, distinct from other activities. At 
minimal, you should also have: full-time access to a computer, printer and modem; 
part-time clerical support; a separate phone line; and budget support for required 
training and basic software. 

You can best do your job if you are kept informed of the status of all health care 
delivery and command activities. It would be most appropriate, therefore, for you to 
attend, if only as an observer, all major command executive meetings. You should 
cultivate the medical and nursing clinical department heads to keep up-to-date on 
current issues and problems. Certainly, the Command Master Chief will want you to 
be informed of enlisted concerns, issues, and problems. Once again, people ask, 
"how much is enough", and once again the answer is not simple. The best answer to 
that question really is another question: "How much time do I need to invest in 
gathering information and keeping current, while still managing to have time to do the 
actual planning?" No simple answer. Ask your peers, and they can give you some 
ideas on how they handle it. Buy-in is important. As a planner, you will need the 
cooperation and assistance of all the major (and several of the minor) players at your 
command. Each of them need to know their efforts and time are contributing to a 
meaningful and useful product. Take the time to inform and involve them. Ask for 
advice and assistance. Take their suggestions, when appropriate. Help them help 
you. 

4. SETTING REALISTIC GOALS . Start off basic and simple. You can't do it all 
at once and you can't change the world in one day. It is crucial that you and your 
supervisor decide on a realistic timetable for what it is you are going to do. What are 
you going to do? First, you will be setting up shop. Next, you will be doing the 
baseline assessments described in this manual. Finally, you will begin the planning 
activities for which this process was designed. Once you start producing meaningful 
and useful results, many people will be giving you lots of ideas and taskings for 
projects. It is important that you learn to prioritize, draw up timetables, and delegate 

(if that is at all possible). Involve others, particularly subject matter experts. They can 
give you realistic information and potential solutions. 



25 Jan 94 12 



5. ESTABLISHING A BASELINE FOR YOUR CATCHMENT AREA . Before you 
can begin to examine specific problems and issues and plan for immediate and long- 
range delivery of health care for your beneficiary population, it is important to take a 
snapshot of your customers - their health care needs, past consumption of health care 
services, and requirements for services. In addition, it is important that you examine 
the various costs of health care services, the health care delivery capabilities in your 
catchment area, and the environment in which you operate. Once you have a 
baseline snapshot of where you are, it will be far easier to look at variations and 
changes. The guidelines presented below are intended to provide you with a 
framework and some of the more standard data elements used by health care 
planners. Some of these data are not formally compiled by either BUM ED or your 
command, so in many instances you will be breaking new ground. The guidelines are 
not intended to be comprehensive and it is expected that you and your command will 
identify additional data elements to include in your baseline. 



C. HEALTH CARE CAPABILITIES ASSESSMENT . After you identify your 
customers and their health care services requirements, you will want to determine 
what's available to do the job. In today's environment, planners must look at 
capabilities in the entire catchment area as well as within their hospital and clinics. At 
the end of this baseline assessment, you will have a snapshot of all the current and 
potential clinical capabilities in your entire catchment area. The narrative below will 
discuss what it is you are to do, and the Tables at the back are included to assist you 
in recording the information. We request that you use these "Tables" provided for 
recording all types of information located at TABs - B & C. 



25 Jan 94 13 



1 . INTERNAL ASSESSMENT . In this section, you will assess the health care 
capabilities of your hospital and clinics. For example, you will determine and record 
where your hospital, clinics, and customers are located; and you will evaluate various 
access to care factors. 



Step One: Map Exercise. 



a. Locate and mark on a map: (1) location of your hospital and (2) all your 
branch clinical facilities. 



b. Where do your beneficiaries live? Mark the locations (where known) of large 
concentrations of beneficiaries (i.e. military housing) in addition to RAPS data on 
population by zip code. Be creative in finding ways to identify where they live (e.g. 
look at the zip code printouts, get into an automobile and drive around). Designate 
the locations by beneficiary type, if at all possible. For example, is there an area 
where many or most of the retirees live, or where young families live? 



c. Your "customers" are not only beneficiaries or patients. Using TABLE 1 as a 
guide, list all the commands you serve, their major activities, and their location. Then, 
on a map, mark the locations of all headquarters and all places where naval personnel 
actually do their work. 



d. Identify and list the accessibility of various types (taxi, buses, shuttles, etc.) of 
transportation to your hospital and clinics. Use TABLE 2 as a guide. Could a person 
who does not drive get to your MTF? Do the operational units have arrangements to 
transport military personnel to sick-call and appointments? 



e. Look at the parking situation at your hospital and clinics. Is there a problem 
(cost, wait time, lack of spaces, walking distance from parking spaces) which could 
discourage people from coming there for care? Use TABLE 3 as a guide for 
recording the information. 



25 Jan 94 14 



f. What is the distance from the areas where most of your beneficiaries live to 
your hospital and clinics? What is the travel time? What about the physical condition 
of the roads? What about traffic congestion? Are there any geographical conditions 
which could be barriers to access? Climate factors? Use TABLE 4 as a guide for 
recording the information. 



g. What is the travel time from various naval worksites to your hospital and 
clinics? What about the physical condition of the roads? What about traffic 
congestion? Are there any geographical conditions which could be barriers to 
access? Climate factors? Use TABLE 4 as a guide for recording the information. 



h. is there a place to eat at the hospital/clinic or within walking distance? Is the 
cost reasonable for a young enlisted family or retired person on a fixed income? Is 
the food nourishing and healthy? 

Look at the information you have just collected. Do you think access to your hospital 
or any of your clinics could be difficult for active duty members or some other 
beneficiaries because of any of these factors? Explain why or why not. Estimate 
how many. Do you want to increase access? What could you change to increase 
access? 



2. EXTERNAL ASSESSMENT , In this section, you will assess the health care 
capabilities of all the other (i.e., non-Navy) sources of health care in your catchment 
area. Do not be concerned with entering into agreements at this time. All you are 
doing now is collecting data. 



a. Locate and mark on a map the location of all the other health care providers in 
your catchment area. Be sure to include - . 



b. All ownership categories: Civilian, Army, Air Force, Uniformed Services 
Treatment Facility (USTF), Coast Guard, Veterans Administration (VA), Indian Health 
Service (IHS). 



25 Jan 94 15 



c. All types: hospitals; free-standing and satellite clinics; solo practice and group 
(HMOs, PPOs, etc.) physicians, nurse practitioners/midwives, physician assistants, 
allied health professionals (e.g. optometrists, podiatrists, etc.). 



d. What is the distance from the areas where most of your beneficiaries live to the 
locations of the other health care providers in your catchment area? What is the travel 
time? What about the physical condition of the roads? What about traffic congestion? 
Are there any geographical conditions which could be barriers to access? Climate 
factors? Use TABLE 4 as a guide for recording the data. 



e. Identify and list the accessibility of various types (taxi, buses, etc) of 
transportation to and from the other health care providers in your catchment area to 
your customers living and workplaces, and to your own hospitals and clinics. Use 
TABLE 2 as a guide for recording the information. 



f. Look at the information you just obtained. Do you think access to the other 
health care providers in your catchment area could be a problem for some 
beneficiaries because of any of these factors? Explain why or why not. Estimate how 

many. 



Step Two: Assess Your Health Care Capabilities. 

3. Assess the Health Care Capabilities of the Other (Non-Naw) Sources . In 
this section, you will take a "snapshot" - but this time of all the "other" (non-Navy) 
sources of health care in your catchment area. This assessment will consist of 
collecting information about the clinical capabilities of all the hospitals, clinics, and 
providers in your catchment area. Do not be concerned if any of these other sources 
are available or want to enter into agreements at this time. All you are doing now is 
collecting data. INVENTORY A is a set of tables designed for easy recording of 
information about all the other sources of health care in your catchment area. 
INVENTORY B will assist you with resource issues. 



a. Use Tables 5A and 5B to record information about each hospital in your 
catchment area. All of this is public information or freely shared within the industry. 



b. Use Table 6 to record information about each clinic (stand-alone or satellite) in 
your catchment area. 



25 Jan 94 16 



c. Use Table 7 to record the numbers of physicians, nurse practitioners, and allied 
health providers, by clinical specialty; and physicians assistants and nurse 
anesthetists. 



d. Identify and list ALL OTHER possible sources of health care providers in your 
catchment area. 



(For example, are there any medical schools, nursing schools, allied health schools? 
Is there a potential pool of volunteers among the military retired population in your 
catchment area?) 



4. SNAP-SHOT OF HOW CARE IS BEING DELIVERED . Now you will take a 
"snapshot" of how health care is being delivered RIGHT NOW to your customers. This 
snapshot will include: (1) the various ways you provide access to clinical services; (2) 
the providers who deliver the care inhouse; and (3) information about referrals in and 
out of your hospital and clinics. Look at how your hospital and branch clinics are 
providing access to care right now. 



a. Use Table 8 and denote by an "X" all the various modes you currently use to 
provide access to inpatient clinical services. 



b. Use Table 9 and denote by an "X" all the various modes you currently use to 
provide access to outpatient clinical services. 



c. Look at WHO is performing health care services at your hospital and branch 

clinics. 



d. Use Table 10 and record the actual numbers in each category of physicians, 
nurse practitioners, physician assistants, nurse midwives, nurse anesthetists, and allied 
health (e.g. pharmacists, podiatrists, optometrists, etc.) or MSC direct care providers. 



25 Jan 94 17 



e. Please note that "reservists" in mutual support roles, even if for only one 
weekend a month, are a potential way to increase access and expand capabilities. 
For example, in some hospitals, reservists use their "weekend drills" to conduct day- 
long pediatrics or gynecology visits. Record/estimate the capabilities, by specialty and 
provider types available during each month. 

f. Look at your referrals: 

(1) What types of cases are being referred to your hospital? 

(2) What are you referring to other hospitals/sources of care? 

g. Use Table 1 1 to record the number of admissions, by clinical service and 
source of referral INTO your hospital. 



h. Use Table 12 to record the number of outpatient clinic visits, by clinical service 
and source of referral INTO your hospital. 



i. Use Table 13 to record the number of referrals, by clinical service, which are 
MADE BY your hospital TO OTHER SOURCES of care. 



j. Are any hospitals or clinics in your area "centers of excellence" for particular 
specialties or procedures? For example, NAVHOSP Bethesda, with the National 
Institutes of Health across the street may wish to enter into sharing agreements. 



k. Do you have a rehabilitation facility in the area which could provide services to 
your beneficiaries? 

I. Are there community-based visiting nurse or home-health services which you 
could utilize? 



m. Are there local alternate sources of emergency transport, care, or actual 
emergency rooms? 



n. Record any other existing sources of health care in your catchment area. Be 
sure to include those which are for preventive/health promotion services as well as for 
acute care. 

25 Jan 94 18 



5. ANTICIPATED CHANGES . As a last step, you will take a "best guess" of 
the future. This will include any anticipated changes in your hospital and clinics (no, 
not billet growth!) and in the "other" sources of care in your catchment area. This is 
the section where you will want to record any ideas about expected changes. For 
example, do you expect/ anticipate any changes in the beneficiary population due to 
new nomeporting or downsizing? Is there a possibility or plan for a new or expanded 
Veterans Administration hospital? Have you heard that a group of civilian obstetricians 
is leaving the catchment area? If the Air Force base closes, how many of the retirees 
do you anticipate will seek services at your hospital? Is the local civilian hospital 
adding a new wing for pediatric cardiology/cardiothorasic surgery? Will new bridge 
construction limit access by increasing the travel time for young enlisted families to the 
naval hospital by one hour? Obviously, for many facilities, BRAC III has already done 
a lot to shape the future., either in terms of downsizing or closure. However, the rate 
of change proposed for BRAC IV will be as great as BRACs I, II and III combined, and 
the experienced gained from previous planning initiatives will be put to good use. 



25 Jan 94 19 



TAB B - INVENTORY A 



o 

o 

s. 



> 

s 

m 



O 

o 

z 



I 

I - 
I 

5!- 



> 

s 
m 

33 
CO 



S 
> 

O 
5 



m 

CO 



25 Jan 94 



20 



o 

<z> 
m 



o 

3 
1 

o 



I 
o 

c 

% 



3J 
O 

c 



25 Jan 94 



21 



TABLE 3 
PARKING ASSESSMENT 
NAVAL HOSPITAL 



LOCATION 


SUFFICIENT 
SPACES 


COST 


WAIT 


WALK TIME 













KEY: 

LOCATION - NAVAL HOSPITAL, CLINIC NAME 

SUFFICIENT SPACES = IS THERE OVERFLOW? ARE THERE PEAK TIMES? IS THERE ENOUGH SPACE? 

COST = IS THERE A MONEY OR OTHER (WAIT TIME, DISTANCE, ETC.) COSTS? 

WAIT TIME = IS THERE A WAIT TIME FOR A SPACE? HOW LONG IS THE AVERAGE WAIT DURNING PEAK HOURS? 

WALK TIME TO MTF = HOW LONG IS THE WALK FROM THE PARKING SPACES TO THE ACTUAL BUILDING? 

ARE THERE BARRIERS RESTRICTIVE TO THOSE WHO HAVE TROUBLE WALKING 
OR WHO HAVE TO USE ARTIFICIAL AIDS TO WALK? 



CM 
c\J 



C 
CO 

~5 

lO 
CM 



TABLE 4 
ACCESS FACTORS 
NAVAL HOSPITAL 



LOCATION 


DISTANCE 


TRAVEL 
TIME 


ROADS 


TRAFFIC 


BARRIERS 















CO 
CM 



KEY: 

LOCATION = MAJOR HOUSING AREA (NAME) OR WORKSITE (NAME) 

DISTANCE = MILES 

TRAVEL TIME » AVERAGE TRAVEL TIME TO MTF. IF MAJOR DIFFERENCE DURING RUSH HOURS. ETC.. NOTE ADDITIONAL TIM 

ROADS = CONDITION OF ROADS (E.G. MAJOR CONSTRUCTION, IMPASSABLE AFTER NOVEMBER 15. ETC.) 

TRAFFIC = ANY MAJOR TIMES OF DAY WHEN MAJOR ROADS ARE HIGHLY CONJESTED? ALTERNATE ROUTES? 

BARRIERS = BARRIERS TO ACCESS, INCLUDING GEOGRAPHICAL AND CLIMATOLOGICAL BARRIERS. 

FOR EXAMPLE: MAJOR BRIDGES, MOUNTAIN RANGES, BODY OF WATER, MONSOON RAINS, ETC. 



c 

CO 

-3 
10 

CM 





a: 
o 
co 

i - 
z 
> 
2 
m 




6 

o 

o 

z 




3 

m 




TOTAL 

UCENSED 

BEDS 




MED/SURG 
BEDS 




PYSCH 
BEDS 




03 

m o 

D CD 

CO 




CD 

£ 

CO 

z 
m 

CO 




EMERGENCY 
ROOM TYPE 



o 

c 

z=g 
>m 

> -i 



coo 
IS I 



CO 



_fii 

> 
o 



o 
> 

I - 

o 
> 



m 

CO 



25 Jan 94 



24 



TABLE 5B 
CURRENT CATCHMENT AREA CLINICAL CAPABILITIES 
NAVAL HOSPITAL 



HOSPITAL NAME 



OPERATING 
ROOMS 



OUTPT 

EXAM 

ROOMS! 



ICU BEDS 
AND 
TYPE 



AVBEDS 
OCCRATE 



ALOS 



ADPL 



LIVE 
BIRTHS 



DISCHARGES 
FY- FY- 



OUTPT VISITS 
FY- FY- 



CM 



cu 

c 

CO 

~3 

m 





o 

c 
z 

o 

z 
> 




5 

o 

o 

z 




3 

m 




OS 

ii 

c/> 




OUTPATIENT 
VISITS 
91 92 






z 
p 

■D 
33 
O 
< 

O 

m 

CO 



o 



o 

c 

DO 

33 

m 

z 

H 
O 

I 
S 
m 



> 
on 



> 



2 

s 



m 



25 Jan 94 



26 



TABLE 7 
CURRENT CATCHMENT AREA CUNICAL CAPABILITIES 
Providers 
(Physician, NP, Nrs Midwife, Nrs Anesthetist, PA, Allied Health Cirect Care Providers) 



CLINICAL SPECIALTY 




CM 



CD 

c 

CD 
-3 

in 

C\J 



TABLE 8 
CURRENT WAYS MTF PROVIDES ACCESS 
Inpatient Clinical Services 



CLINICAL 
SERVICE 



MODE OF DELIVERY 
INHOUSE CONTRACT PARTNERSHIP MEDEVAC VA SHARE OTHER DOti CHAMPUS 



mgdcare: 



00 
CM 



c 



CM 



TABLE 9 
CURRENT WAYS MTF PROVIDES ACCESS 
Outpatient Clinical Services 



CUNICAL 
SERVICE 



MODE OF DELIVERY 
INHOUSE CONTRACT PARTNERSHIP MEDEVAC VA SHARE OTHER DOd CHAM PUS 



MGDCARE 



CM 



c 

03 

—3 

lO 
CM 



TABLE 10 
CURRENT INHOUSE CLINICAL CAPABILITIES 
Number and Source of Providers by Clinical Service 
(Physician, NP, Nrs Midwife, Nrs Anesthetist, PA, MSC Direct Care Providers) 



CLINICAL SERVICE 



SOURCE OF PROVIDERS 



BILLETS 



ONBOARD 



FTE 
CONTRACT 



FTE 
PARTNERSHIP 



CIVILIAN 



RESERVISTS 



O 

CO 



CD 

c 

CD 

-5 

lO 
CM 



TABLE 11 
INPATIENT - ADMISSIONS 
REFERRALS FROM OTHER SOURCES 



CLINICAL SERVICE 


ARMY 


AIR FORCE 


SOURCE OF 
VA 


PROVIDERS 
MEDEVAC 


USTF 


CIVILIAN 


OTHER 



















CO 



c 

CO 

~3 

lO 
OJ 



TABLE 12 
OUTPATIENT - CLINIC VISITS 
REFERRALS FROM OTHER SOURCES 



— '- ' ■ 

CLINICAL SERVICE 


ARMY 


AIR FORCE 


SOURCE OF 
VA 


PROVIDERS 
MEDEVAC 


USTF 


CIVILIAN 


OTHER 



















CM 
CO 



c 

CO 



ID 
CM 





o 

1- 
2 

O 
> 

I - 

CO 

m 

< 

o 
m 




> 
33 




> 

3 
S 

m 




SOURCE OF 
VA 




PROVIDERS 
MEDEVAC 




c 
-n 




O 
< 




o 

in 

3D 



33 

m 
-n 

m 

33 



CO 



3" 

CO 

o 

c 

B 

m 

CO 



25 Jan 94 



33 



TAB C - INVENTORY B 

PART ONE: NAVAL HOSPITAL - Space/Beds 

a. Number of beds routinely currently in use (ADPL) 



b. Number of additional beds which could be supported (with onhand supplies, 
equipment, bed units, personnel, etc.) 



c. Can bed spaces be reconfigured for: 



(1) More efficiency (yes/no) 



(2) Expansion of work-units (yes/no) 
d. Is there any vacant space? 

(1) Within the hospital buildings? 

(2) Adjacent land? 



e. Can existing spaces be reconfigured for: 



(1) More efficiency (yes/no) 



(2) Expansion of work-units (yes/no) 



f. Number of outpatient exam rooms 



25 Jan 94 34 



(1) List clinical departments which have outpatient clinics and space (number 
of rooms) assigned to each: 



g. Could outpatient spaces be reconfigured for: 



(1 ) More efficiency (yes/no) 



(2) Expanded work-units (yes/no) 
h. Number of operating rooms 



(1) Number in use per weekday 



(2) Number in use per weekend day 

(3) Hours per day each is in use 



(4) Number not currently used due to physical readiness or staff 
limitations 



i. Recovery room capabilities. 



(1) Number of patient spaces available 



(2) Number of spaces used each weekday 



(3) Number of spaces used each weekend day 



25 Jan 94 35 



PART TWO: NAVAL HOSPITAL - Ancillary Services 
a. Laboratory capabilities. 



(1) List tests/procedures currently performed by your hospital laboratory on a 
routine basis: 



(2) List tests/procedures currently performed by an outside laboratory for your 
hospital. List test/procedure name and where sent for analysis: 



(3) List tests/procedures currently performed by your hospital laboratory on a 
routine basis for your branch clinics: 



b. Radiology capabilities. 



(1) List tests/ procedures currently performed by your hospital radiology 
department on a routine basis: 



(2) List tests/procedures currently performed by an outside radiology 
department for your hospital. List test/procedure name and where sent for analysis: 



(3) List tests/procedures currently read by an outside radiologist for your 
hospital. List test/procedure name and where radiologist is located: 



c. Pharmacy capabilities: 

(1) Number of prescriptions filled per month 



25 Jan 94 36 



(2) Number of prescriptions not written bv vour MTF providers which are filled 
per month at your pharmacy 



(3) Average weekday (0900 to 1400) wait time 



(4) Number of prescriptions filled for beneficiaries who live outside your 
catchment area 



d. Immunization capabilities. 



(1 ) List the immunizations your hospital currently administers on a routine basis 
(please specify which are for children under age seven; and which are for active duty 
members): 



e. Clinical departments. 

(1) List the names of the formally-designated clinical departments located at 
your hospital: 

(example: podiatry, internal medicine, OB/GYN, general surgery, neurosurgery) 

f. Clinical services. 

(1) List the names of the outpatient clinics and clinical services available at your 
hospital: 

(for example: allergy, pediatric neurology, immunizations, well-baby, hypertension, 
dialysis) 



25 Jan 94 37 



PART THREE: NAVAL HOSPITAL - Manpower/Personnel 



a. Military 

(1) List all authorized military billets, by NEC for enlisted, subspecialty code for 
officers. 



(2) List all onboard military, by NEC, subspecialty, 
b. Civilian 



(1) List all civilian personnel authorizations, by job title. Specify if civil service, 
contract, partnership, or other classification. 



(2) List civilian personnel onboard, by job title. Specify if civil service, contract, 
partnership, or other classification. 



25 Jan 94 38 



PART FOUR: NAVAL HOSPITAL - Training 
a. GME 



(1) List, by specialty, all GME programs at your hospital, including current 
number of faculty and students, by year. 



(2) List all external arrangements you have with local civilian or other federal 
hospitals for GME training or programs. Do you share faculty with any of these 
programs. If "yes", please provide details. How many of your students are assigned 
to these facilities? Please provide details. 



b. Enlisted Training 



(1) List all enlisted medical/nursing training at your hospital, including title and 
number of students per year. 



25 Jan 94 39 



PART FIVE: BRANCH CLINICS Fill in one of the following for each of your branch 

clinics. 



a. BRANCH CLINIC (NAME) 



(1) Number of exam rooms 



(2) Number used for health care 



(3) Number used for other purposes 



b. Could clinical spaces be reconfigured: 



(1) For more efficiency (yes/no) 



(2) For expansion of work-units (yes/no) 
c. Is there any vacant space? 

(1) Within the buildings (yes/no) 

(2) Adjacent land (yes/no) 



d. Laboratory capabilities. 



(1) List tests/procedures currently performed by the clinic's laboratory on a 
routine basis: 



(2) List tests/procedures currently performed by an outside laboratory for the 
clinic. List test/procedure name and where sent for analysis: 



25 Jan 94 40 



e. Radiology capabilities. 



(1) List tests/procedures currently performed by the clinic's radiology 
department on a routine basis: 



(2) List tests/procedures currently performed by an outside radiology 
department for the clinic. List test/procedure name and where sent for analysis: 



(3) List tests/procedures currently read by an outside radiologist for the clinic. 
List test/procedure name and where radiologist is located: 



f. Pharmacy capabilities: 



(1) Number of prescriptions filled per month 



(2) Average weekday (0900 to 1400) wait time 



(3) Number of prescriptions filled for beneficiaries who live outside your 
catchment area 



g. Immunization capabilities. 



(1) List the immunizations the clinic currently administers on a routine basis 
(please specify which are for children under age seven; and which are for active duty 
members): 



h. Clinical services. 

(1) List the names of the clinical services available: 

{example: allergy desensitization injections, immunizations, hypertension screening, 
prenatal care, dietary teaching, acute care, podiatry) 



25 Jan 94 41 



i. Manpower/Personnel 
(1) Military 



(a) List all authorized military billets, by NEC for enlisted, subspecialty code 
for officers. 



(b) List all onboard military, by NEC, subspecialty. 



(2) Civilian 



(a) List all civilian personnel authorizations, by job title. Specify if civil 
service, contract, partnership, or other classification. 



(b) List civilian personnel onboard, by job title. Specify if civil service, 
contract, partnership, or other classification. 



25 Jan 94 42 



D. PLANNING CONSIDERATIONS - Measures of Effectiveness (MOEs). 

MOEs allow us to examine trade-offs among alternative investment strategies by 
realizing changes in one area are brought about by changes in another. Fully 
developed measures of effectiveness will help us achieve a proper balance across our 
corporate goals and ensure we remain focused on our primary mission - supporting 
the operational forces of the Navy and Marine Corps. An understanding and 
appreciation of MTF and corporate Measures of Effectiveness is an important part of 
the planning process. Our experience to date has shown that corporate MOEs are in 
fact different from individual MTF MOE's and direct linking the two is important. 

Navy Medicine's corporate MOEs are divided into four categories: (1) Readiness, 
(2) Quality, (3) Satisfaction, and (4) Resource Management. The goal is to create 
corporate measures and facility measures and to eventually link the two into an 
integrated measurement system. The Navy Medical Information Management Center 
has created a program in which proposed core measures have been identified, 
however the system does not give comparability among navy MTFs. A working group 
has been convened to refine the core measures to make them a meaningful link with 
the corporate measures so that MTFs commanding officers have the opportunity of 
dealing with measures which are important at the facility level, but which might not be 
important at the corporate level. 



1 . READINESS . The readiness measure serves to differentiate our health care 
system from private sector health care systems. The current readiness measures of 
effectiveness are: (1) military returned to duty, (2) operational manning, and (3) 
resource and training system information. Military returned to duty is concerned with 
the number of days that active duty are unavailable due to hospitalization. The goal of 
this measure is to reduce the number of days that active duty members are unable to 
work due to hospitalization or illness. This is expressed by the total hospital days per 
active duty member. Operational readiness shows the percent of fleet billets filled at 
any given point in time. Operational readiness is that percentile of operational 
manning. Operational manning is a major concern for military medicine because of 
our unique Navy and Marine requirements. If there are shortages, they are often filled 
from a military treatment facility which has caused disruption in the continuity of care 
at the hospital. The last area of readiness is the status of resources and training 
systems information. This measures looks at the overall readiness of the fleet 
hospitals and the medical ships. Status of resources and training systems information 
are geared toward the readiness of platforms to deploy and do their mission. 



25 Jan 94 43 



2. QUALITY . The quality measure of effectiveness has been defined to be the 
Joint Commission on Accreditation and Healthcare Organization's Grid Score. This 
measure indicated compliance with defined standards of care. In addition the 
measures of effectiveness provide an important tool in presenting Navy Medicine's 
position to senior Navy leadership, and a baseline for evaluating Navy medicines 
overall performance. The CNO Executive Steering Committee's Health Care Quality 
Management Board composed of 3-star Flags has made Medical Measures of 
Effectiveness one of its highest priority issues. 

3. SATISFACTION . The Satisfaction measure reflects the level of beneficiary 
satisfication with our health care delivery system. This deals with overall beneficiary 
satisfaction within military medicine. It serves to educate providers and customers in 
identifying a place where potential problems may exist. Satisfaction with professional 
competence deals with beneficiaries' impression that they are receiving quality care. 
This provides a measure as to how the patient feels about the encounter with the 
medical provider. Access to care, waiting times, regular source of care and 
emergency room service are the other satisfaction measures for our beneficiaries. 
Waiting time is made up of two components: (1) office wait - the time spent sitting in 
the office waiting to see the provider and (2) appointment wait - the time elapsed 
between when a person requests an appointment and when that person comes into 
the office. Regular source of care is concerned with continuity of care. Can the 
beneficiaries identify a place where they get care when they need it? Do they always 
go to one place to receive care, or do they have to go to different places each time? 
Emergency Room (ER) services seeks to identify the percent of people who do not 
have a regular source of care and go to the ER when they need care. Remember, the 
emergency room is neither the appropriate place for primary care nor the most cost 
effective means to deliver primary care. This measure will look at how well Navy 
medicine is doing at directing patients to the appropriate outpatient setting. 

4. RESOURCE MANAGEMENT . The Resources Management measure deals 
with the optimization of labor and capital. The three major areas are (1) cost per 
beneficiary, (2) inpatient and outpatient cost trends, and (3) obligations per medical 
work unit. Cost per beneficiary is designed to approximate the total cost of treating 
beneficiaries. This cost includes direct, CHAM PUS, co-payments and operational 
costs. Inpatient and outpatient cost trends are designed to look at how much it costs 
to treat each patient in the inpatient or outpatient arena in comparison to what is 
happening in the private sector. The cost per medical work unit is designed to show 
cost trends for treating patients in two major categories, supply dollars per medical 
work unit and total cost per medical work unit. A follow-on to MOEs will be discussed 
in the Utilization Analysis Section. 



25 Jan 94 44 



SECTION II - SPECIFY POPULATION (ESTIMATES AND PROJECTIONS) 



A. INTRODUCTION . It is vital for the health care planner to have accurate 
demographic information about current and future beneficiary population data. The 
population served is the foundation for health care planning. Only recently has the 
need for accurate demographic data become so apparent throughout DOD. In the 
past, beneficiary populations, in terms of size and location have been relatively stable 
and predictable. With the reduction in force structure, BRAC decisions, coordinated 
care implementation, and capitation budgeting, numbers of DoD Health Affairs and 
Service working groups are trying to improve the accuracy of beneficiaries population 
estimates and projections. While results will not be instantaneous, there is evidence of 
progress. For example, the Resources Analysis and Planning System (RAPS) 
database is the only population estimation and projection tool currently available 
throughout DoD, the Services, and to the MTF as well. It is the tool that DoD uses in 
Medical Base Realignment and Closure (BRAC) analysis. While the tool is not perfect, 
it does provide MTF planners with the capability to make projections based on a 
number of key demographic variables. 

Recognizing the importance of RAPS to health care planning, the system has been 
revised to include initial estimates of population shifts caused by BRAC. Population 
and demographic information should, at a minimum, address factors such as age, sex, 
and beneficiary category (RAPS Standardized Report #1). In general, RAPS produces 
beneficiary population estimates and projections by beneficiary type and geographic 
area (e.g., catchment area, non-catchment and State). Current out-year population 
estimates can be based on Base Year FY-92 counts of eligible beneficiaries enrolled in 
the Defense Enrollment Eligibility Reporting System (DEERS), which RAPS will allow 
you to project ahead through 1999. The RAPS database creates four types of 
standard population estimates and projections: 

1. BENEFICIARY POPULATION BY AGE/SEX - This report provides 
projections of beneficiary populations by beneficiary category, age, and sex based on 
the number of eligible beneficiaries enrolled in DEERS. For MTFs, this should initially 
be based on the Catchment area level of analysis. 

2. NAVY AFLOAT COMPONENT OF ACTIVE DUTY & DEPENDENT 
POPULATION - This report provides population projection by age and sex for the 
Navy afloat component. Navy afloat are assigned to locations based upon a linkage 
between Unit Identification Codes (UlCs) and home port zip codes. Dependents of 
Navy afloat are allocated to the same home port location as their sponsor. 

3. BENEFICIARY POPULATION BY SPONSOR SERVICE BRANCH - This 

report identifies the service branch, and gives population by beneficiary category 
based on eligible beneficiaries enrolled in DEERS. 

25 Jan 94 45 



4. BENEFICIARY POPULATION BY LOCATION - This report summarizes 
population by location. It identifies the location, and the total population for each 
beneficiary category. This report is generated at the catchment area or higher level, 
but not for the Zip Code level. 

Most basic population estimates can be conducted using the age, sex and 
beneficiary category information in the first standard report category. The other 
standard report categories can provide information that will be useful as individual local 
circumstances require, and MTF planners are encouraged to become familiar with all 
capabilities of RAPS. 

Inpatient Catchment areas are defined as sets of zip codes having a radius within 
40 miles of the zip code of US military hospitals. Non catchment area population for a 
given state includes beneficiaries whose zip codes are within the state but not within 
any catchment area. Since the catchment area population for a given state may 
include beneficiaries residing in a bordering state, note that, in some cases, adding the 
catchment and noncatchment populations for a state will not represent the state's total 
beneficiary population. 



B. MILITARY BENEFICIARY POPULATION ESTIMATES AND PROJECTIONS . To 
begin population analysis, the MTF planner must have access to the RAPS database 
and the RAPS Model User's Guide. For access into the RAPS database and the most 
current user guides, contact the Defense Medical Information Systems (DM IS) Office at 
1 800 627-DMIS. RAPS identification codes must be known for your MTF in order to 
run RAPS reports (See RAPS User's Guide). 

a. Location Code: (see appendix B of the RAPS User's Guide) 

b. State/Country Aggregate Code: (see appendix C of the RAPS User's 

Guide) 

c. Service Area Aggregate Code: (see appendix C of the User's Guide) 



The following report(s) will identify current estimates and project population in your 
catchment area (population with zip codes having radius within 40 miles of the zip 
code of the military hospital). Service Area will appear at the top of projection run if 
your MTF is considered to be part of an overlapping service area (circles around a 
pair of hospitals are considered part of the an overlapping service area if at least 25 
percent of the population within 40 miles of one facility is also within 40 miles of the 
other). 



25 Jan 94 46 



1. REPORT #1 - RAPS Population Projections for Catchment Area . 



(1) Type of implementation: 

a. Select: 1) Redefined Historical Catchment Areas 

(2) RAPS Options: 

a. Select: 1 ) Population Projections by on FY-92 

(3) Projection Years: 

a. Type: 94,95,96,97,98,99 

(4) Population Report Types: 

a. Select: 1) Beneficiary Population by Age/sex 

b. Select: 3) Branch of Service 

(5) Output Explanation Options: 

a. Select: 1) Include Explanation with Output 

(6) Location Concept: 

a. Select: 1) Inpatient Catchment Area Concept 

(7) Aggregation Types: 

a. Select: 1) Individual Catchment/Noncatchment Area 

(8) Individual Location: 

a. Type: (Location Code) 'See Top of Page' 



(9) Modification Options: 

a. Select: 1) Baseline Projections 

(10) Running RAPS Report: 

a. Return to Main Menu 

b. Select: 4) Execute Vax Command from $ Prompt 

c. Type: 'TYPE POP.OUT 



The RAPS users manual will detail the methodologies and assumptions used in 
developing the projections. Read these and become familiar with them. 



25 Jan 94 47 



C. Optional Reports . 



1 . REPORT #2 - SERVICE AREA REPORT - If your MTF is part of an 
overlapping catchment area, you may be interested in seeing population projections 
for those MTF(s) in the area. For Service Area Report, rerun Report #1, modify 
step(s): 

(6) Aggregation Types: 

a. Select: 2) Services Areas 

(7) Service Areas: 

a. Type: (6009) 'See Top of Page 1' 

(7a) Reporting Levels: 

a. Select: 3) Reports for both individual and 
Aggregate Locations 



2. REPORT #3 - STATE/COUNTRY (OVERSEAS) REPORT - Shows 
population projections for state or foreign country by: (1) catchment area, (2) non- 
catchment area, or (3) both catchment/non-catchment area. For State/Country 
Report, rerun Report #1, modify step{s): 

(6) Aggregation Types: 

a. Select: 3) States (and\or overseas countries) 

(7a) Catchment/noncatchment Status: 

a. Select: 1) Catchment areas only 
(7b) Service Branch: 

a. Select: 2) Navy catchment area only 

(7c) Reporting Levels: 

a. Select: 3) Reports for both individual and 
aggregate locations 

Recently, RAPS has been updated to incorporate effects of BRAC population shifts. 



25 Jan 94 48 



D. NAVAL MEDICAL CLINICS . The beneficiary populations and geographic areas 
served by Naval Medical Clinics are not designated as catchment areas but their staffs 
should conduct similar demographic analyses. Clinics and Branch Medical Clinics 
come under respective MTFs and catchment areas. However when the Clinic or 
Branch Medical Clinic is not located in a catchment area, demographic analyses 
needs to be done as well. The planner will have to identify the zip codes surrounding 
these Clinics and contact the RAPS program manager directly to request population 
projections by specific zip codes. This is explained below. 



E. POPULATION BY ZIP CODE . It is not only useful to know the size of the 
beneficiary population served, but where those beneficiaries are located in your 
catchment area. As described in the Draft Capabilities Assessment, this is important in 
identifying the proximity of civilian physicians to our beneficiaries for the establishment 
of networks, and in identifying geographic barriers to the delivery of health care. 

The recommended method of gaining Zip Code information on beneficiaries is to 
request the information from the RAPS Program Manager, the Defense Medical 
Information Systems (DM IS) Office at 1 800 627-DMIS. The RAPS system allocates 
population to Zip Code in the catchment area by allocating the active duty member to 
the zip code of his assigned UlC and the beneficiaries and retirees to the zip code of 
residence. All MTF planners should develop Zip Code - based maps for their 
catchment areas which displays the location of the eligible population by Zip Code and 
beneficiary category. 

F. RAPS LIMITATIONS AND EFFORTS TO IMPROVE . 

1 . Efforts are underway to have RAPS base years updated with an attempt to 
keep RAPS and DMDC numbers as close as possible. 

2. While RAPS incorporates projected population shifts resulting from BRAC 
actions, there are limitations. RAPS compares reductions in active force caused by 
BRAC with projected POM force levels. RAPS spreads the "difference" between POM 
force levels and BRAC reduction proportionally across CONUS. 

3. Population estimates on a zip code basis are not available through the 
standard RAPS user's package. However, zip code specific information on 
beneficiaries can be requested through the DMIS Information Center, 1-800-627-3647. 

4. RAPS overseas population projections are suspect because active duty 
members often bring dependents overseas, even if on an unaccompanied tour. In 
addition, ships assigned to home ports will visit other ports overseas, increasing 
workload, although RAPS technically assigns this population to the home-port. The 
development of a more appropriate methodology for overseas MTFs is a high priority. 

25 Jan 94 49 



5. No standardized definition exists for catchment areas of clinics located 
outside hospital catchment areas (e.g. New Orleans, Key West). The RAPS system 
will identify beneficiaries residing within 20 and 40 miles of the clinic. 

6. Retirees' mailing addresses may not be where they actually reside, thus 
affecting the RAPS population estimates. RAPS is not able to account for those 
retirees who spend significant time in more than one location during the year (snow- 
birds). 

7. The RAPS database does not include any civilian workers employed by the 
military. Civilian employees need to be identified because of Occupational Safety and 
Health Administration (OSHA) requirements for health services and screening to be 
provided by the MTF. Therefore, a separate assessment of the civilian workers 
population within each catchment area is necessary. 

G. CIVILIAN POPULATION ESTIMATES . Many of our clinics and MTFs serve a 
significant number of civilians through occupational health, occupational medicine and 
other program. Civilian worker data from each command within your catchment area 
should be sorted into the following four risk categories as defined by OPNAVINST 
5100.23B as reported by the Navy Environmental Health Center (NEHC). 



Cat. 1: Shipyard Workers 

Cat. 2: Naval Air Rework Facility 

Public Works Centers 

Marine Corps Logistic Centers 

Ship Repair Facilities 
Cat. 3: Naval Regional Medical Commands 

Research and Development Laboratories 

Naval Weapon Stations 

Naval Supply Centers 

Naval Air Stations 

Naval Support Activities 

25 Jan 94 50 



Printing and Publishing Centers 
Naval Regional Dental Centers 
Tenders 

Floating Drydocks 
Cat. 4: All other assignments at shore facilities 

CURRENT CIVILIAN POPULATION IN CATCHMENT AREA 



Command 


Risk 
Cat. 


Occu. 
Series 


No. of 
Civilians 


Type of Care 
Req. by OSHA 
















































































































Total 











This level of baseline analysis should provide information about the numbers of 
civilian workers and their health care risk categories. The same kinds of basic 
information about future Dept of Navy civilian employee trends should be developed 
by working with the civilian personnel offices. 



Analysis : 



1 . Are there plans to increase/decrease the number of civilian workers at any of the 
commands within your MTF catchment area? 



2. How will these changes affect the types of care you provide? 
25 Jan 94 51 



H. Reporting Requirements . The MTF population analysis should, at a minimum 
include the following: 



1. RAPS 1994 thru 1999 Population estimates and demographic analysis 
based on FY-92 base year. 



2. Graphically display the percent of the population that resides in each zip 
code in your catchment area on a Map. This will provide a visual aide as well as allow 
you to identify planning issues arising form the location and dispersion of beneficiaries. 



3. Analyze the mix of your beneficiary categories by age, sex, branch of 
service and other demographic factors. It will provide the baseline for the analysis of 
utilization patterns in the next section. 



25 Jan 94 52 



TAB D - POPULATION REPORT EXAMPLES 



RAPS MODEL FY92 BASELINE POPULATION ESTIMATES 

REDEFINED HISTORICAL CATCHMENT AREAS 
NH XXXXXXXXX 



POPULATION BY AGE/SEX 





ACTIVE 


DEPS OF 


MED 


ELG 


DEPS OF 




DEPS OF 






AGE/SEX 


DUTY 


ACT DTY 


NG/RES 


NG/RES 


RETIRED 


RETIRED 


SURVIVR 


TOTAL 


00-04/M 


-- 


5498 




— 


176 


-— 


77 


9 


5760 


05-14/M 


— 


6237 




— 


109 


— 


687 


47 


7080 


15-17/M 


— 


810 




— 


9 


— 


409 


29 


1257 


18-24/M 


24595 


537 




865 


8 


9 


541 


68 


26623 


25-34/M 


8970 


152 




235 


8 


42 


11 


42 


9460 


35-44/M 


3331 


38 




35 


4 


807 


8 


14 


4237 


45-64/M 


315 


19 




6 


1 


3326 


9 


3 


3679 


65+ /M 


— — 


6 




— 





885 


6 





897 


00-04/F 


-._ 


5278 




— 


187 


— 


95 


15 


5575 


05-14/F 


— 


5952 




— 


96 


— 


608 


59 


6715 


15-17/F 


-— 


892 




-_ 


13 


— . 


396 


26 


1327 


18-24/F 


1120 


6882 




43 


275 


7 


540 


40 


8907 


25-34/F 


538 


7121 




32 


161 


13 


143 


40 


8048 


35-44/F 


174 


2852 




2 


31 


16 


950 


78 


4103 


45-64/F 


12 


470 




1 


6 


36 


2952 


354 


3831 


65+ /F 


— 


20 




— 





32 


653 


338 


1043 



TOTAL 



39055 



42764 



1219 



1084 



5173 



8085 



1162 



98542 



25 Jan 94 



53 



RAPS MODEL FY92 BASELINE POPULATION ESTIMATES 

SEATTLE/TACOMA SERVICE AREA 
ALL DoD CATCHMENT BENEFICIARIES 



POPULATION BY SPONSOR SERVICE BRANCH 



SPONSOR 


ACTIVE 


DEPS OF 


MED ELG 


DEPS OF 




DEPS OF 






SERVICE 


DUTY 


ACT DTY 


NG/RES 


NG/RES 


RETIRED 


RETIRED 


SURVIVR 


TOTAL 


ARMY 


17938 


28340 


1951 


2987 


15315 


20274 


3790 


90595 


NAVY 


5415 


12299 


724 


973 


11459 


14902 


2194 


47966 


AFLOAT 


11713 


13878 


— 


— 


— 


— 


— 


25591 


USMC 


501 


739 


38 


45 


1154 


1384 


200 


4061 


USAF 


5183 


8419 


473 


744 


11209 


14137 


1680 


41845 


USCG 


779 


1730 


24 


6 


1203 


1627 


212 


5581 


OTHER 


223 


256 





2 


117 


148 


52 


798 



TOTAL 



41752 



65661 



3210 



4757 



40457 



52472 



8128 216437 



* Service Area Includes: 



MADIGAN AMC-FT LEWIS 

NH BERMERTON 

PACIFIC MEDICAL USTF SEATTLE 



25 Jan 94 



54 



RAPS POPULATION PROJECTION REPORT 
FY94 BASED UPON FY92 BASELINE 
REDEFINED HISTORICAL CATCHMENT AREAS 

CATCHMENTS NORTH CAROLINA 
ALL DoD CATCHMENT BENEFICIARIES 



POPULATION BY AGE/ SEX 





ACTIVE 


DEPS OF 


MED ELG 


DEPS OF 




DEPS OF 






AGE/ SEX 


DUTY 


ACT DTY 


NG/RES 


NG/RES 


RETIRED 


RETIRED 


SURVIVR 


TOTAL 


00-04/M 


— 


15997 


— 


597 


— 


407 


39 


17040 


05-14/M 


— 


20113 


— 


836 


-- 


3032 


231 


24212 


15-17/M 


— 


2885 


— 


94 


— 


1851 


116 


4946 


18-24/M 


46250 


1992 


1354 


72 


40 


2632 


220 


52560 


25-34/M 


30028 


666 


971 


46 


228 


79 


61 


32079 


35-44/M 


12180 


219 


365 


21 


3931 


40 


45 


16801 


45-64/M 


1258 


80 


105 


5 


17770 


32 


11 


19261 


65+ /M 


— 


27 


— 





6245 


18 


8 


6298 


00-04/F 


— 


15201 


— 


576 


— 


371 


41 


16189 


05-14/F 


-- 


19261 


— 


770 


-- 


2992 


238 


23261 


15-17/F 


— 


3012 


— 


98 


— 


1946 


139 


5195 


18-24/F 


3619 


17575 


172 


637 


16 


2819 


211 


25049 


25-34/F 


2981 


23181 


193 


803 


51 


737 


99 


28045 


35-44/F 


869 


9622 


48 


328 


122 


4777 


298 


16064 


45-64/F 


54 


1589 


8 


81 


139 


16067 


2248 


20186 


65+ /F 


— 


120 


™ 


2 


107 


4104 


2492 


6825 


TOTAL 


97239 


131540 


3216 


4966 


28649 


41904 


6497 


314011 



25 Jan 94 



55 



SECTION IV - ASSESS NEED 



A. INTRODUCTION . The "assess demand" section will discuss health care 
services that have historically been consumed by our beneficiaries. Assess need is 
another perspective that planners will address for health care services delivered to the 
population being served. It is important that a common definition of medical need be 
used. According to health care economics and planning theorist, medical need is 
defined as the services required to attain or maintain the health of a population, which 
may be different from the services historically consumed. While wartime medical 
planners traditionally have dealt with medical need in terms of morbidity rates applied 
prospectively to the populations at risk, peacetime health care planners have been 
limited in their ability to fully address medical need. They have had to rely on historical 
utilization, not prospective analysis of medical need. Ideally, planning tools dealing 
with medical need would allow the planner to identify health care delivery trends based 
on the size and demographic characteristics of a population, not strictly upon the 
area's historical utilization. We are assembling a body of literature, data sources and 
information on models available. HMO's may have significant experience in 
forecasting medical need. We are developing tools that will allow planners to begin 
this process. As better information and methodologies evolve we will distribute these 
to the field. 

B. EXAMPLE . Assessing need relies on a good demographic profile, which in 
turn is developed through a well-defined issue. The first step in assessing need is 
forecasting morbidity for the population being studied. In looking at knee injuries for a 
specific population, the planner would first consult epidemiological data for a similar 
population to find an expected rate of knee injuries. The next step is to decide on the 
level of health desired with respect to the injury or disease, in our example, it might 
be safe to say that the level of health desired is a fully functioning knee. Then the 
planner translates the incidence of injury or disease into the health services required to 
attain the level of health specified. This is where the local planner uses published or 
local treatment protocols to determine the services expected. For example, an injured 
knee may require orthopedic surgery, a series of orthopedic clinic outpatient visits, 
and a course of physical therapy. Thus, the planner has taken a population defined 
by an issue, and translated it into the health care services required to meet the defined 
medical need. Another facet of assessing need is within the health promotion 
component of health care delivery. Even if there is no injury or disease, we want to 
maintain a particular level of health in our beneficiaries -- particularly active duty 
members. Once we decide on the level of health we want to maintain, we can decide 
what health care services our active duty sailors ought to have. 



25 Jan 94 56 



Now that the planner knows the services necessary to meet medical need and the 
services that have been provided to meet the historical demand, the two will be 
compared to see if there are differences and the reason for those differences, or 
analysis of variance. Returning to our injured knees example, we may find that the 
met or historical demand for orthopedic care related to knee injuries may far exceed 
what is expected in a similar civilian population. Investigation would likely show that 
the level and type of activity of the population serves as a reason for the variance, and 
leads the planner to estimate the total requirement for health care services based on 
demand, rather than need. An example illustrating the opposite might be the 
necessary to vaccinate our younger beneficiaries with a new vaccine. This vaccination 
would not appear in an examination of met or historical demand, but it would appear 
in an examination of the targeted population in light of medical need. In this situation, 
need is the driving factor in determining the totality of the requirement for that 
population. Thus, planners have to look at need and demand and synthesize these 
into a requirement for health care. This analysis of variance throughout the process is 
important for at least two reasons - first, it stresses using data to make decisions and 
its objective is to get the process "in control". This does not mean, for example, that 
each hospital should have the same length of stay for each DRG, but rather that the 
length of stay is appropriate at each of our hospitals, according to prevailing local 
circumstances. 

C. "NEEDS" - ONGOING TOOL DEVELOPMENT The clinical/medical needs 
module will probably be the last one ready for your use because of its complexity and 
the vast amount of data which must be organized to ensure the process is valid. 
SHARICON, Incorporated assisted BUMED planners to complete the first phase of the 
design by identifying the sources of medical/clinical needs data. Included were 
sources of data about morbidity and health promotion guidelines by demographic 
characteristics. BUMED, the Medical Department Specialty Advisors, and NMIMC will 
now need to determine which of these data to include in the needs assessment 
module, how to access them, and how to organize them into databases. The final 
step will consist of developing a model which will enable programmers to actually 
design the clinical/medical needs module. What we hope to provide you is a module 
in the Executive Information System (EIS) which will start with the demographic 
characteristics of the population of interest and produce an output of the predicted 
morbidity and health promotion guidelines. For further reading on "assessing need" 
see Enclosure (3). 

D. RETROSPECTIVE CASE-MIX ANALYSIS SYSTEM fRCMAS) NORMS AND 
EXPECTANCY RATES . Planners should be aware that the RCMAS data system uses 
Direct Care, Civilian Health and Medical Program of the Uniformed Services 
(CHAMPS), Uniformed Services Treatment Facility (USTF), and civilian normative data 
to provide statistics of observed versus expected workload, utilization and cost. For 
further information and/or training for RCMAS use, contact the DM IS information 
Center at 1 800 627-DMIS. 

25 Jan 94 57 



SECTION V - ASSESS DEMAND (UTILIZATION ANALYSIS) 



A. INTRODUCTION . Utilization analysis takes into consideration the types and 
amounts of care delivered to our beneficiaries, our direct care and CHAMPUS 
workload. Customarily, we have looked at health care workload in two ways; 
historically and in aggregate. This approach has a major underlying assumption that 
the way we deliver care and the populations we serve are going to change little; that 
what happened in the past is a good predictor of what will happen in the future. All 
indications show that this assumption will no longer be valid. With downsizing of the 
Services, the populations we now serve will rapidly change in terms of location, 
composition and thus affect the way we deliver care. In addition, inpatient care is 
shifting to outpatient care and inpatient surgical procedures to same day surgeries. 
Therefore, planners will have to expand their analytical focus to a prospective and 
population oriented way of looking at workload. That is, expressing workload in terms 
of the amount of services and the frequency which the population receives these 
services. On the ambulatory care side, the utilization rate may be expressed in terms 
of outpatient visits per capita per year; on the inpatient side, in terms of discharges or 
patient days per thousand beneficiaries, per year. With this approach we can isolate 
the effects of population and demographics from changes in workload caused by 
changes in practice patterns. These utilization rates can be applied to the projected 
population estimates to arrive at future estimates of workload and requirements for 
health care services in the catchment area. 



B. HISTORICAL DEMAND AND CURRENT UTILIZATION . The Managed Care 
Query Applications (MCQA) system will be used to retrieve catchment area historical 
and current workload. MCQA was developed as a result of CHAMPUS data based on 
episodes of care and allows a more timely, single source access to CHAMPUS and 
MTF workload data. The direct care data comes from Biometrics files and CHAMPUS 
data files are provided by the Office of the Civilian Health and Medical Programs of the 
Uniformed Services (OCHAMPUS). MCQA will be used to identify catchment area 
outpatient workload by clinical service and admissions by major diagnostic category. 



The Naval Medical Information Management Center is responsible for MCQA and 
has designed standardized reports for the purpose of identifying total direct care, 
CHAMPUS, Supplemental Care and NAVCARE workload data for Navy catchment 
areas. Planners should be aware that Supplemental Care data is counted as part of 
"total" workload. When supplemental care days have not been accurately coded on 
the standard inpatient data record, the MTF receives no credit for this workload. 
Incorporating NAVCARE workload will not be without its own problems. Currently 
workload is reported in aggregate. It is anticipated that sometime in FY 1994 
NAVCARE data will be available by beneficiary category, but not by age. For planning 

25 Jan 94 58 



purposes, the pediatric portion of the NAVCARE workload should be estimated as 
follows. Determine the percentage of the beneficiary population age 14 and under 
(from RAPS) and apply this percentage to the total NAVCARE workload to estimate 
the total portion of NAVCARE workload attributable to pediatrics. The remainder of 
the NAVCARE workload should be allocated to primary care workload. If mammo- 
graphy workload is broken out it should be counted with radiology workload. This 
type of approach will give some better, though not perfect, definition to the care being 
provided in the NAVCARE clinics. Although utilization planning data can be obtained 
from several data sources, it is recommended that MTF planners use these fixed 
reports for consistency. 

Each of the following reports should be developed at the clinical service level for 
outpatient visits and MDC for inpatients. For purposes of analyzing catchment area 
utilization trends, a clinical service level of detail will be sufficient. However, as 
planners develop specific delivery alternatives and business plans, analysis at the DRG 
or patient specific level may be required. Analysis at the DRG level is likely to be 
required as the Coordinated Care evaluation proceeds. Navy health care planning 
guidance will use DRG-specific information in the development of MTF-specific 
business plans and the planning tools for this later part of the process will allow the 
health care planners to comply with evolving Coordinated Care guidance. 



C. DIRECT CARE AND CHAMPUS WORKLOAD DATA . Using MCQA will give the 
planner the ability to deal with one of the most frustrating planning issues - the 
seeming incompatibility of MEPRS and CHAMPUS outpatient workload data. 
CHAMPUS uses categories to aggregate workload which do not easily "map" into the 
MEPRS work centers. In particular, the CHAMPUS Health Care Summary Report 
(HCSR) does not contain clinical service categories to easily identify outpatient care 
provided in the areas of pediatrics, family practice, primary care, or emergency room 
visits, because they are rolled into other clinical categories. Mismatches such as these 
frustrate planners' attempts at determining a total catchment area requirement for 
pediatrics or primary care, for example. MCQA can help planners with this problem 
because of the ability to identify and summarize CHAMPUS workload by the specialty 
of the provider rendering the health care service (e.g., how many CHAMPUS 
outpatient visits were provided by pediatricians or family practitioners). These 
specialty categories have been mapped into MEPRS work centers which give a more 
accurate picture from that given in the CHAMPUS Health Care Summary Report. The 
mapping of CHAMPUS inpatient information into MEPRS work centers remains 
problematic; however, MCQA can aggregate CHAMPUS and MTF inpatient workload 
at MDC or DRG levels, but there is no current methodology to map MDC's or DRG's 
into MEPRS workcenters. Until the development of such a methodology, CHAMPUS 
and MTF admission data will be based on MDC. 



25 Jan 94 59 



D. HISTORICAL UTILIZATION . At least 3 years of historical workload at the 
clinical service level should be examined by the MTF planner and is available through 
MCQA to determine direct care and CHAMPUS workload for FY 91-93. This historical 
data should be reviewed and analyzed for catchment area trends, variations and/or 
seasonalities of clinical workload. There may be obvious seasonalities due to the 
arrival of students at training installations that would affect MTF workload. There also 
may be changes in the relative proportion of workload between the MTF and 
CHAMPUS which may need to be correlated to changes in the numbers of providers 
in certain specialties available at the MTF. 



E. CURRENT UTILIZATION DATA . For health care planning analyses, current 
utilization means the most recent complete fiscal year, rather than the budget 
execution year. This is for several reasons; (1) to give a full years worth of data, (2) to 
be comparable with RAPS analysis periods, which are full fiscal years, and (3) to 
provide more complete and accurate CHAMPUS workload data than execution year 
would provide. To complete this section of the analysis, planners must have access 
to MCQA. MCQA can be accessed through your telecommunications software 
packages over the Local Area Network (LAN) directly into NMIMC's data base. Point 
of Contact for identification codes and passwords to MCQA can be received through 
John Weiland, NMIMC Bethesda, who can be reached at (301) 295-0868. Logon to 
MCQA and run BUMED-93 PLANNING REPORTS, fixed reports 1 and 2 are for 
standard analysis. These reports contain utilization information as well as 
demographic information, such as age, sex and beneficiary category. For outpatient 
data, the level of detail is at the clinical service level, mapping CHAMPUS to MEPRS 
work centers. For inpatient workload, CHAMPUS and direct care workload are 
presented at the MDC level. If you are connected to the LAN, you can access MCQA 
as follows: 

1) LOAD YOUR NETWORK SOFTWARE 

2) select: NETWORK MENUS 

3) select: ACCESS TO MVS 

4) at the screen "the following application id's are available to telnet', 

type: TSO 

5) type: Your UserlD 

6) type: Your Password 

7) at the TSO/E Information Center Facility User Services Screen, 

select: 8) PDF - ISPF/PDF Services then RETURN 

25 Jan 94 60 



8) at the ISPF/PDF Option Menu: type TSO MCQA 

You should now be connected to MCQA, enter your natural password and follow the 
instructions displayed on your screen until you reach the Managed Care Query 
Application's MAIN MENU SCREEN 

9) select: #4 (BUMED-93 Planning Reports) 

Continue to follow instructions on screen to obtain the reports necessary to do 
your analysis. Once you have determined your selection criteria, the system will ask 
you to confirm that the information you are requesting is indeed correct. Xsys will 
appear at the bottom right hand corner of screen in bold to let the user know the 
system is actively retrieving the requested data. After the data is retrieved and the 
report(s) is on the screen press the PF9 key - which saves your documents on the 
hard drive as REPORTS. To download and print your report(s) you must exit out of 
MCQA (follow instructions on screen to exit) and return to the C prompt. 



1) at the C prompt type: ftp mvs (the system will prompt you with userid for logging 

in) 

2) type your userlD and return (system will prompt you with userid accepted) 

3) type your password and return (system will prompt you with LOGON complete) 

4) at the prompt ftp:nmdsc.nmdsc.nnmcnavy.mil> type: GET REPORTS 

5) at the prompt local file (default) leave blank and return 

6) system will prompt you with data transfer completed closing connection 

7) at the > prompt type: quit 

8) type: mfprint REPORTS compress 

in order to get your reports to print in conjunction with the paper length and width, 
there is a support program called mfprint. MFPRINT has been included for your 
convenience. Download MFPRINT before running reports. 

Guidance : Run the following Reports using the MCQA Data Base, for FY-91 thru FY- 
93. 



25 Jan 94 61 



o REPORT 1: MTF AND CHAMPUS ADMISSIONS - This report identifies direct 
care admissions by major diagnostic category for all beneficiaries that were admitted 
to your MTF and CHAMPUS admissions for those beneficiaries that belong to your 
catchment area. The "In Catchment Area" column - this identifies admissions for those 
beneficiaries receiving care at your MTF that belong to your catchment area. The "Out 
Catchment Area" column - this identifies admissions of those beneficiaries who did not 
belong to your catchment area but came to your MTF for treatment. 

o REPORT 2; MTF AMBULATORY CARE AND CHAMPUS VISITS - This report 
identifies direct care and CHAMPUS outpatient visits by clinical service. 

o REPORT 3: NON-AVAILABILITY STATEMENTS BY CATCHMENT AREA 

o REPORT 4: OUTSIDE CATCHMENT AREA 



Analysis: Based on the above MCQA Reports, complete the Tables below: 



TABLE 1. MTF ADMISSIONS/VISITS 



Patient Origin 


Admissions 
FY- 

n 100% 


Visits 
FY- 
n 100% 


Inside Catchment Area 






Outside Catchment Area 






Total Admissions 


100% 


100% 



TABLE 2. TOTAL CATCHMENT AREA BENEFICIARY ADMISSIONS/VISITS 



MTF Site 


Admissions 
FY- 
n 100% 


Visits 
FY- 
n 100% 


MTF 






CHAMPUS 






Total Admissions 


100% 


100% 



25 Jan 94 



62 



TABLE 3. CATCHMENT AREA BENEFICIARY ADMISSIONS/VISITS TO ALL MTFS 



MTF Site 


Admissions 
FY- 
n 100% 


Visits 
FY- 
n 100% 


MTF Inside Catchment Area 






MTF Outside Catchment Area 






Total Admissions 


100% 


100% 



Analyses of this type, done by MDC, should give a clear picture of patient referral 
patterns, in and out of your catchment area. 

F. PATIENT MIGRATION AND REFERRAL . The above tables look at patient 
referral and migration patterns in and out of the MTFs catchment area and specifically 
address managed care issues. A fundamental issue for the planner is the flow of 
patients in and out of his MTF catchment area and the reasons why. The reason why 
this kind of information may become more important in the future is financial and 
because of capitation budgeting. Currently, if a patient from your catchment area is 
referred to an Army hospital, the care received is paid for by that hospital, not by your 
MTF's O&M.N funds. Thus, today there exists an incentive to refer these patients out 
of your catchment area. In the future your MTF may, in fact, be charged by the other 
MTF for the care received by your catchment area patients. This kind of information is 
key to establishing baseline information for make-buy decisions in business plans. 



Analysis : 

1 . What is the overall migration pattern within your catchment area for specific DRGs? 



2. Do you have more out-migration (patients from inside the catchment area going 
outside the catchment area for care) or in-migration (patients from outside the 
catchment area coming into the catchment area for care)? 



3. Do you have little of either (a static situation)? 



25 Jan 94 



63 



4. Where do the out-migrating patients go for care - In catchment area or outside 
catchment area? Teaching facilities should expect more in-migration while smaller 
MTFs may expect more out-migration. MTFs in the South may have in-migration due 
to snow-birds. Overseas MTFs may have in-migration due to Sailors and Marines 
assigned to ships or due to non-sponsored dependents. 



5. Are there certain clinical specialties where the in/out-migration is particularly high? 

NOTE: 

RCMAS AS A UTILIZATION TOOL . ROMAS is becoming an increasingly important 
standardized health care planning tool within DOD. RCMAS offers many capabilities to 
analyze and compare inpatient MTF and CHAMPUS workload by DRG. All planners 
are encouraged to become familiar with the capabilities and uses of RCMAS. 



25 Jan 94 64 



G. UTILIZATION ANALYSIS & EVALUATION OF HEALTH CARE OUTCOMES . 
Utilization analysis is key to evaluating the effectiveness of delivering health care in the 
Military Health Services System. Utilization analysis will also be a key part of the 
Coordinated Care Program Evaluation strategy, directed by OASD(HA) and is key to 
Navy Medicine's recently developed measures of effectiveness. The planning tools 
and methodologies developed for Navy Health Care planners will complement the 
approaches being developed for use in the Navy's Measures of Effectiveness. 

The Measures of Effectiveness have four effectiveness criteria and three patterns of 
variation which combine to form a matrix for the evaluation of Navy health care 
delivery. The four effectiveness criteria are: 

* Resources (Cost of Care) 

* Quality of Care 

* Customer Satisfaction 

* Readiness Posture 



The three patterns of variation are: 

* Variations in a population's utilization patterns - the volume of health services 
provided to a population. 

* Variations in the referral patterns - the site for those health services (e.g., ^ 
military or civilian). - : t 

* Variations in the clinical treatment patterns required to produce health care 
episodes in the MTFs. 



This kind of an approach will emphasize the analysis of variation between MTFs in 
the same geographic area, of the same peer group, among all services. Ultimately the 
analysis could be carried to individual departments within an MTF, for example to 
identify causes of variation in Lengths of Stay for the same DRG among different 
physicians using RCMAS. While this portion of the planning cookbook does not 
address all aspects of variation in health care delivery, it will at least provide a 
framework for the planner to address initial aspects of variation. 



25 Jan 94 65 



H. CUSTOMER EXPECTATIONS AND SURVEYS . In addition to utilization 
analysis, our planning process will have to take into account the expectations of our 
beneficiaries and customers. A fundamental precept of good health care management 
is to keep in touch with the customers - our patients, staffs, and line counterparts, to 
name a few. The predominant way to gather information about customer expectations 
is through the use of surveys. The process of incorporating customer expectations is 
likely to affect how we deliver care. An example may be changing the operating hours 
of the pediatrics clinic to better meet the needs of working mothers, after surveying 
this customer group. On a DoD level, OASD(HA) is coordinating an annual survey of 
Navy medical beneficiaries in all catchment areas, and the Center for Naval Analysis 
(CNA) is conducting customer surveys as a part of the TriCare project evaluation in 
Tidewater. 



I. UTILIZATION ANALYSIS SUMMARY . Completion of this utilization analysis 
gives the planner the ability to evaluate and analyze what took place in the past, 
confirm what is currently happening and to forecast what will transpire in the future. 
Identifying trends, seasonalities and variations is a good predictor for planning and 
preparing for the unexpected, ahead of time. MCQA developed standardized fixed 
reports for both Direct Care and CHAMPUS admissions and visits. Supplemental Care 
Days and NAVCARE visits are also identified. Patient Migration and Referral Patterns 
gives a clear picture of beneficiaries coming in and going out of the MTF catchment 
area for health care services. Projections for out-years and planning for that purpose 
will be done through this utilization analysis in direct relationship with specifications of 
the population in which you serve. 



25 Jan 94 66 



TAB E - MCQA UTILIZATION REPORT EXAMPLES 



NH CAMP LEJEUHE NC FISCAL YEAR 92 
MUSCULOSKELETAL t CONNECTIVE T1S 



PATIENT 


AGE 


DIRECT 




TOT 


CHAHPU5 




TOT 


IN 


OUT 


SUPP 


CATEGORY 


CATEGORY 


M 


F 


DIRECT 


H 


F 


CHAHPUS 


CATCH 
AREA 


CATCH 
AREA 


CARE 


ACTIVE DUTY 


AGES 18-24 


540 


29 


569 











340 


229 







AGES 25-34 


329 


28 


357 











299 


58 







AGES 35-44 


148 


6 


154 


t 





1 


142 


12 


p 




AGES 45-64 


13 





13 


15 


a 


15 


13 








DEPENDENTS OF ACTIVE DUTY 


AGES 00-04 


1 


3 


4 


5 


4 


9 


4 










AGES 05-14 


5 


2 


7 


10 


5 


15 


7 










AGES 15-17 


3 


1 


4 


2 





2 


4 










AGES 18-24 





6 


6 


2 


6 


8 


6 










AGES 25-34 





7 


7 





14 


14 


7 










AGES 35-44 


1 


5 


6 





4 


4 


6 










AGES 45-64 





2 


2 





2 


2 


2 










AGE UNKNOU 











2 


1 


3 











RETIREES 


AGES 45-64 


5 





5 











5 










AGES 65+ 


2 





2 











2 








DEPENDENTS OF RETIRED / DECEASED AGES 15-17 











2 





2 













AGES 16-24 














1 


1 













AGES 35-44 














1 


1 













AGES 45-64 





4 


4 





17 


17 


4 










AGES 65+ 





3 


3 











3 








OTHER 


AGES 18-24 


1 





1 














1 







AGES 45-64 


1 


a 


1 


D 








1 








MAJOR DIAGNOSTIC CATEGORY TOTAL 




1,049 


96 


1,145 


39 


55 


94 


645 


300 






25 Jan 94 



67 



OUTPATIENT VISITS BT PATIENT CATEGORY 
DIRECT CARE/CHAMPUS FOR FISCAL YEAR 93 
FACILITY: 0091 NN CAMP LEJEUNE NC 
-- FIRST LINE OF EACH PROFESSIONAL SERVICE IS OIRECT CARE 
-- SECOND LINE OF EACH PROFESSIONAL SERVICE IS CHAHPOS 



(CLINICS INCLUDED) 



UCA 


SERVICE 


ACTOU 1 


DEP ACTDU 1 


tETIRED DEPRET-DEC 


OTHER 


TOTALS UT 


TOTALS 


BAA 


INTMED CLINIC 


3,190 


1,545 


1,993 


1,244 


92 


6,064 


318 






D 




















BAK 


NEUROLOGY CLINIC 


1,699 


285 


25 


5 


4 


2,018 


73 



























BAL 


NUTRITION CL 


422 


185 


88 


67 


1 


763 


9 



























BAP 


DERMATOLOGY CL 


2,897 


1,250 


595 


441 


16 


5,199 


112 


















o' 








DBA 


GENSURGERY CL 


2,108 


1,928 


952 


1,085 


17 


6,090 


210 



























BBD 


OPTHALHOLOGY CL 


744 


1,042 


865 


673 


18 


3,342 


92 



























BBF 


OTORKINOLARY CL 


1,401 


439 


117 


79 


7 


2,043 


62 



























BBI 


UROLOGY CLINIC 


1,320 


44 


175 


14 


1 


1,554 


61 



























BCB 


GYNECOLOGY CL 


2,137 


4,170 


31 


511 


34 


6,883 


162 



























BCC 


OBSTETRICS CL 


2,939 


11,928 


8 


131 


56 


15,062 


391 



























BOA 


PEDIATRIC CLINIC 


23 


17,601 





198 


37 


17,859 


357 



























SEA 


ORTHOPEDIC CL 


8,237 


563 


82 


145 


32 


9,059 


327 



























BEB 


CAST CLINIC 


8B9 


2B8 


41 


40 


9 


1,267 


25 



























BEE 


ORTHO APPLIAN CL 


509 


74 


11 


2 





596 


19 



























8EF 


PODIATRY CLINIC 


1,826 


543 


101 


215 


6 


2,691 


56 



























BFO 


MENTAL HEALTH CL 


3,359 


1,545 


118 


112 


3 


5,137 


170 



























BFE 


SOCIAL WORK CL 


119 


710 


33 


68 


4 


934 


19 












D 











D 


BFF 


SUBSTANCE ABUSE 


845 


213 


3 


2 


2 


1,065 


35 



























BHA 


PRIMARY CARE CLS 


61,226 


200 


21 


4 


32 


61,483 


1,617 



























BHB 


NED EXAM CL 


8,366 











16 


8,382 


273 



























BHC 


OPTOMETRY CLINIC 


4,021 


386 


132 


95 


87 


4,721 


76 



























BNO 


AUDIOLOGY CLINIC 


293 


132 


39 


21 


2 


487 


7 



























BHF 


COM HEALTH CL 


59 


106 


60 


104 


10 


339 


13 



























1HG 


OCCUP HEALTH CL 


6,055 











3,361 


9,416 


240 



25 Jan 94 



68 



Page 



94-01-13 16:14:10 



NON-AVAILABILITY STATEMENTS 
MAJOR DIAGNOSTIC CATEGORY 
BY PATIENT TYPE AMD PRIHART REASON 
IN-PATIENT DIAGNOSTIC CATEGORIES 
FY 92 OCT/SEP NAS/DEER COMB 



**** NH CAHP LEJEUNE NC 




#*** 


PATIEN1 


r TYPE 






PRIMARY REASON 




MAJOR [ 


TOTAL 


DEP 


DEP 


RET 


SURV 


FORM | 


FAC 


PROF 


FAC 


NED 


DIAGNOSTIC j 




ACDU 


RET 






SPOUS | 


TEMP 


TEMP 


PROF 


INAP 


CATEGORY | 
1 












I 

I 


MA 


NA 


PERM 
NA 




NERVOUS SYSTEM 


30 


26 


2 


2 








1 


8 


19 


2 


EYE DISORDERS 


5 


2 


1 


1 


1 








2 


2 


1 


EAR/NOSE/THROAT 


21 


16 


2 


3 








2 


7 


7 


5 


RESP SYSTEM 


83 


67 


6 


10 








2 


14 


16 


51 


CIRC SYSTEM 


5fl 


17 


18 


20 


3 





2 


22 


27 


7 


DIGESTIVE SYSTEM 


81 


70 


5 


5 


1 





4 


10 


29 


33 


HEPATOBILIARY/PANCREA 


20 


11 


7 


1 


1 





3 


9 


3 


5 


MUSCLE/TISSUE DISORDE 


101 


69 


18 


13 


1 





2 


96 


3 





SKIN DISORDERS 


21 


17 


2 


2 











6 


13 


2 


ENDOCRINE DISORDERS 


15 


11 


4 





D 








4 


8 


3 


KIDNEY DISORDERS 


52 


26 


15 


6 


1 





1 


42 


5 


4 


MALE REPRO 


7 


6 





1 











6 


1 





FEMALE REPRO 


BO 


67 


10 





3 





10 


43 


5 


22 


PREGNANCY 


1799 


1772 


23 





4 





10 


1733 


21 


35 


NEUBORN 


78 


7a 














7 


2 


59 


10 


RLODO DISORDERS 


7 


4 


3 





D 








1 


3 


3 


HYELO DISORDERS 


4 


2 


1 


1 














4 





PARASITIC DISORDERS 


12 


12 

















3 


1 


8 


MENTAL HEALTH 


290 


234 


39 


9 


7 


1 


283 


1 


4 


2 


CHEHCL/SUBSTHCE ABUSE 


22 


15 


1 


3 


3 





22 











ACCIDENTS / INJURIES 


2 


2 

















1 





1 


BURNS 


1 


1 




















1 





HEALTH STATUS 


13 


7 


2 


1 


3 








5 





8 


■PATIENT TOTALS 


2802 


2534 


159 


80 


28 


1 


349 


2015 


231 


201 



25 Jan 94 



69 



INPATIENT VISITS AT OTHER HAW HTFS FY 
06/13/93 1St«;».5 



93 



CATCHHEMT MTF 



PROVIDER NTF 



HOC 

CODE MAJOR DIAGNOSIS CATEGORY 



NUMBER 
OF 

PATIENTS 
SEEN 



NH CAMP LEJEUME NC 



HNHC BETHESOA HO 



TOTAL NUMBER OF PATIENTS SEEN BY NNHC BETHESOA HD 

NH CHERRY POINT NC 






UNKNOWN «0C 


t 


2 


EYE DISORDER 


2 

3 

67 





UNKNOWN HOC 


1 


NERVOUS SYSTEM 


12 


2 


EYE DISORDER 


1 


3 


EAR,NOSE r H0UTK, &TNROAT 


15 


4 


RESPIRATORY SYSTEM 


40 


5 


CIRCULATORY SYSTEM 


a 


6 


DIGESTIVE SYSTEM 


130 


7 


HEPATOBILARY SYSTEM AND PANCREAS 


24 


8 


MUSCULOSKELETAL t CONNECTIVE TISSUE 


43 


9 


SKIN, SUBCUTANEOUS TISSUE * BREAST 


43 



25 Jan 94 



70 



SECTION IV - DETERMINING REQUIREMENTS FOR HEALTH CARE SERVICES 



A. INTRODUCTION . There is no magic formula for projecting future requirements 
for health care services. Having said this, our best guess is a synthesis of knowledge 
about the likely future demographics of the beneficiary population, what health care 
services the population has historically used, and whether this historical usage and 
workload might differ from the actual medical needs of the population. Future delivery 
requirements are influenced by other factors not directly under the control of the 
planner, such as system wide resource availability, technology and health care policy 
to name a few. Nonetheless, the planner must consider the effects of these large 
scale factors, as well as local factors such as facility constraints and MTF productivity. 
As discussed in the last section, determining future requirements also should involve a 
synthesis of medical need with medical demand or historical utilization trends. As 
tools are developed to synthesize need and demand, they will be incorporated into the 
planning process. Until the "medical need" portion of the toolbox is more fully 
developed, health care planners will have to rely on applying historical utilization (use 
rates) to the projected change in the beneficiary population. 

RAPS is the best tool we have at the MTF level to project the effects of population 
changes on health care service delivery requirements (expressed as outpatient visits 
and admissions). The RAPS model will project the amount of expected future 
workload by clinical service by applying utilization rates to population estimates and 
projections. Projections are assembled from Biometrics MTF workload data and 
CHAM PUS claims data. Demand is projected for future years assuming that base 
year inpatient and outpatient workload wjN change in direct relationship to changes in 
the population (that is, that the utilization rates will remain constant). RAPS assumes 
that the MTF is operating at capacity of the base year; therefore, any increase in 
catchment area workload in future years is presumed to be justified by nondirect care 
sources such as CHAMPUS. Characteristics for hospitals and stand-alone clinics such 
as bed size, clinical constraints and occupancy rates can be modified. This will allow 
the MTF planner to use RAPS to reflect future planning scenarios and potentially to 
allow the MTF to recover some of the projected increase in health care demand which 
would otherwise be satisfied by nondirect care sources. 



B. Compatibility of CHAMPUS. MEPRS and RAPS . The clinical service categories 
for CHAMPUS, MEPRS, and RAPS are all different and not directly compatible. This is 
not an insurmountable problem. For outpatient workload, this can be worked around. 
As described previously, MCQA will allow CHAMPUS outpatient data to be mapped 
into MEPRS work centers, which, in turn, will map into RAPS outpatient categories. 
Since RAPS inpatient base year data comes from DMIS it should be pretty consistent 
with actual MTF workload. 



25 Jan 94 71 



C. RAPS UTILIZATION PROJECTION REPORTS. 



1. REPORT #1 - INPATIENT DIRECT CARE - Dispositions and beddays 
performed at the MTF by clinical service and beneficiary type. 

2. REPORT #2 - INPATIENT NONDIRECT CARE - Nondirect care 
admissions and beddays allocated by clinical service and beneficiary type. (Nondirect 
care can contain estimates of supplemental care and Medicare, in addition to 
CHAMPUS). Nondirect care for active duty and for beneficiaries aged 65+ is 
translated as care purchased for the civilian sector. 

3. REPORT #3 - OUTPATIENT DIRECT CARE - Outpatient workload 
performed at the MTF by clinical area and beneficiary type. 

4. REPORT #4- OUTPATIENT NONDIRECT CARE - Nondirect outpatient 
visits by clinical service and beneficiary type for both catchment and noncatchment 
areas. (Nondirect care can contain estimates of supplemental care and Medicare, in 
addition to CHAMPUS). Nondirect care for active duty and for beneficiaries aged 65+ 
is translated as care purchased for the civilian sector. Nondirect care for dependents 
of active duty and under age 65 is translated as CHAMPUS care. 



The most current user guides can be obtained by contacting the Defense Medical 
Information Systems (DMIS) Office at 1 800 627-DMIS. RAPS identification codes must 
be defined for your MTF in order to run RAPS reports (See RAPS User's Guide). 

To complete this section of the assessment, you must use the RAPS database and 
the RAPS Model User's Guide. Logon to RAPS. 

a. Location Code: (see appendix B of RAPS User's Guide) 

b. State/Country Aggregate Code: (see appendix C of User's Guide) 

c. Service Area Aggregate Code: (see appendix C of User's Guide) 



NOTE: For a detailed descriptions of the above RAPS reports, include "explanation" 
option when running the clinical services projections. 



1. RAPS Options: 

a. Select: 2) Workload and Cost Projections 

b. Enter one Year (between 92 and 99) for analysis 



25 Jan 94 72 



2. Report Subjects: 

a. Select: 1) Utilization Reports 

3. Utilization Report Types: 

a. Select: 1) Inpatient Direct Care Reports 

2) Inpatient Nondirect Care Reports 

3) Outpatient Direct Care Reports 

4) Outpatient Nondirect Care Reports 

5) Inpatient Local Destination Direct Care Reports 

4. Patient Origins for Inpatient Facility Workload Reports 
a. Select: 1) Local 

2) Nonlocal 

5. Output Explanation Options: 

a. Select: 1) Include Explanation with Output 



6. Aggregation Types: 

a. Select: 1) Individual Locations 

7. Modification Options: 

a. Select: 1) Baseline Projections 



8. Running RAPS Report: 

a. Return to Main Menu 

b. Select: 4) Execute Vax Command from $ Prompt 

c. Type: 'TYPE UTIL.OUT' for screen or printer output 

d. Reports can be downloaded 



Analysis: 

1. Run Clinical Service Utilization Reports for each fiscal year up to 1999. 



2. List required clinical specialties. Do you now provide all the clinical 
specialties that your beneficiaries require? 



3. Is it possible to recapture your CHAMPUS visits? 
25 Jan 94 73 



D. ANALYSIS . If the population and demographic projections of a catchment area 
are relatively stable, the future RAPS workload projections are likely to be relatively 
stable. However, with changes being brought about by current and upcoming BRAC 
activities, for example, many catchment areas will be experiencing significant 
population turbulence and changes in workload with the catchment area. In these 
cases it is very important to look at the population changes by age, sex, and 
beneficiary category in attempting to project workload. Population changes affect 
mostly active duty personnel (if those associated with students and schools) will have 
to be accommodated through the MTF and the direct care system. Population 
changes affecting CHAMPUS eligible beneficiaries will affect the entire catchment area 
delivery system. 

E. UTILIZATION RATES /TRADE-OFF FACTORS . In considering utilization 
projections, planners must consider utilization trade-off factors. In a nutshell, utilization 
trade-off factors predict that health care utilization rates will change when a CHAMPUS 
eligible beneficiary goes from the direct care system to CHAMPUS and vice-versa. 
Because of the costs of CHAMPUS co-pays and deductibles, a beneficiary going from 
the direct care system to CHAMPUS care statistically will use less health care services 
and going from CHAMPUS to direct care will use more health care services. This is 
important to consider as planners develop future utilization scenarios which may have 
beneficiaries shifting between delivery alternatives. 

RAPS takes the trade-off factor into account in the following way: RAPS assumes 
the MTF operates at full capacity and accommodates active duty first. Any projected 
workload that could be brought into the MTF increases due to CHAMPUS population 
is shifted to non-direct care using trade off factors. Similarly, unless otherwise 
specified, any decreases in workload at the MTF, are taken from CHAMPUS workload. 
The RAPS trade-off methodology is explained in detail in the RAPS Users Guide. 

As mentioned in the introduction, for planning purposes, utilization rates are 
generally expressed as outpatient visits per capita per year and discharges and/or 
patient days. Their usefulness lies in the fact that they can be used for comparison 
and projection independent of the underlying population size, or can be used to 
predict the effects of changes in population. RAPS contains inpatient and outpatient 
utilization rates which are expressed in terms of outpatient visits per capita by clinical 
category and admissions and patient days is compatible with MEPRS work centers 
only. RAPS is not available at the DRG or MDC level, for inpatient workload. RAPS 
will be used for forecasting overall levels of MTF catchment area demand and provider 
requirements, using DoD Health Care Manpower standards. Since the Manpower 
Standards are based on outpatient workload, the shortcomings in the inpatient data 
can be tolerated. 



25 Jan 94 74 



F. COMPARISONS - ACTUAL UTILIZATION VERSUS RAPS EXPECTED 
UTILIZATION . In order to make worthwhile utilization projections using RAPS, the MTF 
planner will have to compare RAPS projections for FY-92 with actual FY-92 data from 
MCQA. For outpatient workload, the total utilization in MCQA (by MEPRS category) 
will have to be mapped into the RAPS outpatient clinical service categories. The 
planner should use a Lotus spreadsheet to translate total current utilization into the 
RAPS clinical service categories. The MTF planner should then examine the FY-92 
actual outpatient utilization data with the RAPS FY-92 projected outpatient utilization to 
identify any clinical service workload where significant discrepancies exist and which 
require additional analysis. After comparing the actual data against the projected 
workload, if there is a substantial difference, greater than +/- 5%, the planner should 
initiate further investigation. If the data is still questionable, check your population data 
and if any alterations are necessary, incorporate changes under the RAPS modification 
option, and rerun report. This will adjust your new projections and allow you to 
acquire better estimates of future projections. For inpatient workload, comparisons 
total actual workload and RAPS projected workload will have to suffice. The MTF is 
free to attempt comparisons between MDCs and RAPS inpatient categories, as well. 



G. JOINT HEALTHCARE MANPOWER STANDARDS (JHMS) . In order to 
determine the types and number of health care providers required at each of our Navy 
hospitals and clinics, the Joint Health Manpower Standards (JHMS) Directive 6025.12 
and it's methodology will be used as the tool for determining health care provider 
requirements. Through the use of these staffing standards, you, as planners will have 
a uniformed process for determining what's needed at your particular facility in 
accordance with the rest of Navy medicine. These standards provide a basis for 
performance levels and provides guidance for determining demand for workcenter 
specialties. The standards have been classified into three categories. Type (1) was 
developed by determining man-hours required to do a job through the use of time 
studies, work sampling, or a combination of both. The remaining standards are 
developed by regression analysis and must satisfy specific statistical measures. Type 
(1) standards are considered engineered standards. Types (2) and (3) were 
developed by determining manpower requirements when the clinical specialty was not 
appropriate for engineered methods. The determinant for the classification of these 
standards is in the developmental methodology. 



25 Jan 94 75 



Each standard defines the workload factor, to be used in application of the 
standard. The workload factors are reported through MEPRS and DMIS. If new 
workload factors are identified for use with the standards, they will be added to DMIS. 
Each standard contains specific instructions for applying the standard to the clinical 
workcenter specialties. Deviations from these standards are only permitted when 
written justification has been approved. These standards should be reapplied annually 
to determine requirements and serve as a guide for allocating authorized billets. For 
those clinical areas that do not have staffing standard developed, please contact the 
specialty advisor in order to determine the most appropriate methodology. Efficiency 
review methodologies used to determine resources required where no staffing 
standard exist, should be reviewed by BUM ED prior to incorporation into this planning 
methodology. This process is done manually, preferably on a spreadsheet using the 
JHMS standards and your MEPRS workload data. You can obtain a copy of the Joint 
Healthcare Manpower Standards, DoD 6025.12-STD through your normal publications 
channel or from the U.S. Department of Commerce, National Technical Information 
Service, 5285 Port Royal Road, Springfield, VA 22161. 



Analysis: 

1 . List all specialties and the number of physicians required to support the 
requirement. 



25 Jan 94 76 



H. NEW WAYS OF DOING BUSINESS . Planners will identify many kinds of health 
care services; outpatient care, inpatient care, preventive care, as well as the 
appropriate provider of the services. In addition, we are in a period of transition in the 
kinds of services we provided (i.e., shift from inpatient to ambulatory visits) and in who 
provides the care (i.e., shift from specialist to primary care providers and physician 
extenders with an emphasis on healthy people). The transition pressures are well 
summarized in two papers recently developed by BUMED staff which are included as 
appendices. Enclosure (4), written by LCDR Molly Moon, USNR, defines key issues 
involved in the delivery of primary care services in Navy Medicine. The paper 
emphasizes the wide range of primary care providers available in the Navy Medical 
Department, as well as issues involved in moving from specialty care to a primary care 
environment. The implication is that in future planning we not only look at how we did 
business in the past, but also how we want to conduct business in the future and to 
plan accordingly. 

Enclosure (5), developed by Captain William Rowley, MC, USN, describes an HMO 
approach for determining physician requirements. It is based on ratios of physicians 
to population served, rather than historical workload generated by a given population. 
The value of this approach is that it provides a reality check for historically derived 
utilization rates and workload projection methodologies using RAPS, MEPRS, etc. 
Both represent trends that may influence Navy Health care delivery. This is especially 
true for primary care, as Navy's active force downsizes and emphasis shift to 
providing care to other active forces. Also, capitation based budgeting will shift 
planning emphasis away from historical workload to move of a population based 
planning approach. As discussed in the Medical Need section, determining future 
requirements ideally should involve a synthesis of medical need with historical demand 
or historical utilization trends. As tools are developed to synthesize need and demand 
they will be incorporated into the planning process. Our current capabilities rely on 
applying RAPS utilization rates to the projected beneficiary population to determine 
workload and then applying the Joint Medical Manpower Standards to the projected 
workload to estimate provider requirements. Performing this type of analysis on a 
catchment area basis would provide some future estimate of provider requirement for 
the entire beneficiary population. Applied to a more specific population segment, it 
ought provide the basis for determining the number of FTE's required for a PPO 
network, or to determine the capacity for an MTF in a particular clinical service. 
Among the tools available to convert workload to manpower are the Joint Healthcare 
Manpower Standards. In addition, the HMO mode is a physicians to population based 
approach which provides a generally applied tool to compare current or projected 
provider requirements with the civilian delivery systems. These comparisons should 
be performed with the understanding that the readiness component of our activities, 
while incorporated into the manpower standards, are not reflected in civilian 
comparisons. 



25 Jan 94 77 



TAB F - RAPS UTILIZATION REPORT EXAMPLES (PROJECTIONS) 



V 4.50 12/21/92 



RAPS MODEL UTILIZATION PROJECTION REPORT JAN 5, 1994 
FY99 BASED UPON FY90 BASE YEAR UTILIZATION 11:16:57 
LONG TERM PERSPECTIVE BRAC 11.01 09/22/92 

NH TWENTYNINE PALMS 



DIRECT 


CARE INPATIENT WORKLOAD ; 


: LOCAL ORIGIN 






ACTIVE 


DEP ACT 


OTHERS 






CLINICAL AREA 


DUTY 


< 65 


< 65 


OVER 64 


TOTAL 


INTERNAL MEDICINE 




BEDDAY 


589 


220 


83 


106 


998 


DISPOS 


206 


91 


16 


17 


330 


CARDIOLOGY 












BEDDAY 

















DISPOS 

















NEUROLOGY 












BEDDAY 

















DISPOS 

















PEDIATRICS 












BEDDAY 





164 


1 





165 


DISPOS 





65 


1 





66 


OTHER MEDICAL 












BEDDAY 

















DISPOS 

















GENERAL SURGERY 












BEDDAY 


133 


88 


17 


10 


248 


DISPOS 


72 


49 


12 


6 


139 


ORTHOPEDICS 












BEDDAY 


247 


22 


6 





275 


DISPOS 


144 


11 


3 





158 


OTOLARYNGOLOGY 












BEDDAY 

















DISPOS 

















UROLOGY 












BEDDAY 

















DISPOS 

















GYNECOLOGY 












BEDDAY 


36 


209 


28 


7 


280 


DISPOS 


20 


120 


7 


1 


148 


OTHER SURGERY 












BEDDAY 

















DISPOS 

















OBSTETRICS 












BEDDAY 


149 


1408 


59 


-' 


1616 


DISPOS 


65 


615 


26 





706 


PSYCHIATRY 












BEDDAY 

















DISPOS 

















ALL CLINICAL AREAS 












BEDDAY 


1154 


2111 


194 


123 


3582 


DISPOS 


507 


951 


65 


24 


1547 



25 Jan 94 



78 



RAPS MODEL UTILIZATION PROJECTION REPORT 
FY99 BASED UPON FY90 BASE YEAR UTILIZATION 
NH TWENTYNIHE PALMS 



JAN 5, 1994 
11:16:57 



NONDIRECT CARE INPATIENT WORKLOAD : 





ACTIVE 


DEP ACT 


OTHERS 






CLINICAL AREA 


DUTY 


< 65 


< 65 


OVER 64 


TOTAL 


INTERNAL MEDICINE 












BEDDAY 





228 


151 


63 


442 


DISPOS 





60 


18 


11 


89 


CARDIOLOGY 












BEDDAY 





29 


153 





182 


DISPOS 





5 


28 





33 


NEUROLOGY 




t 








BEDDAY 





8 


2 





10 


DISPOS 





3 


2 





5 


PEDIATRICS 












BEDDAY 





294 


8 





302 


DISPOS 





86 


2 





88 


OTHER MEDICAL 












BEDDAY 





96 


117 





213 


DISPOS 





8 


19 





27 


GENERAL SURGERY 












BEDDAY 





180 


62 


25 


267 


DISPOS 





43 


16 


6 


65 


ORTHOPEDICS 












BEDDAY 





234 


22 


1 


257 


DISPOS 





38 


7 


1 


46 


OPHTHALMOLOGY 












BEDDAY 





5 








5 


DISPOS 





2 








2 


OTOLARYNGOLOGY 












BEDDAY 





5 


16 


2 


23 


DISPOS 





5 


3 


1 


9 


UROLOGY 












BEDDAY 





32 


42 


3 


77 


DISPOS 





5 


4 


1 


10 


GYNECOLOGY 












BEDDAY 





116 


6 


3 


125 


DISPOS 





55 


2 





57 


OTHER SURGERY 












BEDDAY 





250 


72 


10 


332 


DISPOS 





5 


4 


1 


10 


OBSTETRICS 












BEDDAY 





754 


24 





778 


DISPOS 





293 


11 





304 


PSYCHIATRY 












BEDDAY 





2658 


564 





3222 


DISPOS 





118 


12 





130 


ALL CLINICAL AREAS 












BEDDAY 





4889 


1239 


107 


6235 


DISPOS 





726 


128 


21 


875 



25 Jan 94 



79 



V 4.50 12/21/92 



RAPS MODEL UTILIZATION PROJECTION REPORT JAN 5, 1994 
FY99 BASED UPON FY90 BASE YEAR UTILIZATION 11:16:57 
LONG TERM PERSPECTIVE BRAC 11.01 09/22/92 

HH TWENTYNINE PALMS 



DIRECT CARE (WITH ROLLUP) OUTPATIENT VISITS 



CLINICAL AREA 


ACTIVE 
DUTY 


DEP ACT 
< 65 


OTHERS 
< 65 


OVER 64 


TOTAL 


INTERNAL MEDICINE 

FAM PRAC/PRIMARY CARE 

FLIGHT/UNDERSEAS MED 

PEDIATRICS 

ALLERGY 

CARDIOLOGY 

DERMATOLOGY 

NEUROLOGY 

EMERGENCY MEDICINE 


381 
55736 




2 

6592 


412 

10311 



6228 





10 



11826 


553 

1729 



85 





1 



754 


201 
365 






273 


1547 

68141 



6313 





13 



19445 


GENERAL SURGERY 

ORTHOPEDICS 

OPHTHALMOLOGY 

OTOLARYNGOLOGY 

UROLOGY 

GYNECOLOGY 


830 

2630 







471 


548 

395 







2165 


163 

73 







113 


59 

27 







41 


1600 

3125 







2790 


OBSTETRICS 


695 


6460 


270 





7425 


PSYCHIATRY 


1813 


497 


101 


12 


2423 


OPTOMETRY 


2588 


1419 


254 


91 


4352 


ALL CLINICAL AREAS 


7173B 


40271 


4096 


1069 


117174 



25 Jan 94 



80 



V 4.50 12/21/92 



RAPS MODEL UTILIZATION PROJECTION REPORT 
FYS 9 BASED UPON FY90 BASE YEAR UTILIZATION 



JAN 5, 1994 
11:16:57 



LONG TERM PERSPECTIVE 
NH TWENTYNINE PALMS 



BRAC 11.01 09/22/92 



NONDIRECT CARE OUTPATIENT VISITS 
CATCHMENT AREAS ONLY 





ACTIVE 


DEP ACT 


OTHERS 






CLINICAL AREA 


DUTY 



< 65 
16384 


< 65 
3424 


OVER 64 
508 


TOTAL 


MEDICAL/PRIMARY CARE 


20316 


ALLERGY 


150 


882 


168 


77 


1277 


CARDIOLOGY 


10 


71 


66 


38 


185 


DERMATOLOGY 





582 


114 





696 


NEUROLOGY 


23 


125 


24 


15 


187 


EMERGENCY MEDICINE 





3340 


171 


139 


3650 


GENERAL SURGERY 





972 


652 


30 


1654 


ORTHOPEDICS 





1325 


531 


36 


1892 


OPHTHALMOLOGY 


3B 


645 


613 


94 


1390 


OTOLARYNGOLOGY 


60 


1231 


274 


44 


1609 


UROLOGY 


49 


366 


401 


64 


880 


GYNECOLOGY 





2612 


228 


19 


2859 


PSYCHIATRY 





4653 


1267 


11 


6131 


OPTOMETRY 

















ALL CLINICAL AREAS 


330 


33388 


7933 


1075 


42726 



25 Jan 94 



81 



SECTION VII - FORECAST RESOURCE REQUIREMENTS 



A. INTRODUCTION . For the purposes of planning issues covered in this 
document, the concept "forecast resource requirements" will include ways to: 

1) analyze and distribute workload and provider requirements identified in the previous 
section, between the direct care system (MTF) and other alternative sources of care, 
(2) identify available inpatient and outpatient costing methodologies, and (3) give the 
potential impact of capitation budgeting methodologies on the resource allocation 
process. 

B. ALLOCATION OF RESOURCES BETWEEN DIRECT CARE SYSTEM AND 
OTHER ALTERNATIVE SOURCES OF CARE . A fundamental concept of managed 
care in the military setting is the balancing of delivery of care between the direct care 
system and other health care delivery alternatives in a cost effective manner. Given 
the historical stability of our populations served and of the number and location of our 
hospitals and providers, this has been a process of managing at the margin - moving 
some provider billets between hospitals, contracting for some services at some 
hospitals, or establishing internal or external partnerships. We have looked at our 
catchment area management responsibilities primarily in terms of bringing workload 
back into the MTF without a full understanding of cost implications or whether or not it 
was the most cost effective thing to do in terms of the entire catchment area. In fact 
catchment area management involves several pots of money - O&MN, MPN, 
CHAMPUS, Navcare, Contracts and OMA to name a few. 

Events have moved swiftly to change our sense of the "status quo". On a macro 
level, the implementation of CRI in California and Hawaii represented significant, large 
scale change, particularly for Navy, with our population focus in California. As 
importantly, on a smaller scale, the establishment of the external partnership 
agreement at Naval Hospital Newport also represents a fundamental shift from the 
status quo. All inpatient workload was shifted to the local civilian hospital, with Navy 
providers receiving staff privileges. In this process, many billets assigned to the Naval 
Hospital were ultimately redistributed throughout the claimancy. Most recently, the 
BRAC process is resulting in major reshuffling of resources within the system. This 
includes closing naval hospitals Oakland, Long Beach, Philadelphia and Orlando; the 
downsizing of NH Charleston; and the augmentation of facilities such as NH Great 
Lakes, to accommodate increased beneficiary population as a result of BRAC. Thus, 
the "lid is off" of our status quo environment. BRAC IV will drive even more significant 
change in the system. The need to identify our resource requirements and allocate 
them better is more important than ever. 



25 Jan 94 82 



C. MEPRS COST ALLOCATION COMPARED WITH CIVILIAN . In order to do this 
type of allocation, both direct care and CHAMPUS costs need to be identified and 
compared, and some method of estimating the marginal cost of bringing workload into 
the direct care system must be available. Traditionally, we have had better success in 
identifying CHAMPUS costs (both inpatient and outpatient) than MTF costs. This is 
because inpatient information is derived from the individual inpatient billing record and 
the outpatient encounters from billing records under CPT4 and ICD9 coding 
procedures. Direct care inpatient and outpatient costing are hampered by the their 
reliance on MEPRS driven average cost data. 



D. INPATIENT/OUTPATIENT COSTING METHODOLOGIES . Because the MEPRS 
system does not generate a true individual patient bill, rather an average cost, the 
current system can not offer true case-by-case cost comparisons between the same 
DRGs for MTFs and CHAMPUS or other delivery alternatives. However, tools are 
available which refine the MEPRS data on a DRG basis to offer a better comparison of 
average DRG costs between MTF and civilian counterparts. 



E. EXECUTIVE INFORMATION SYSTEM (EIS1 FINANCIAL MODULE . The Navy 
Medicine EIS, under the sponsorship of the Naval Medical Information Management 
Center (NMIMC) at Bethesda, has as one of its components a Financial Module. 
Among the capabilities of the module is a "Make-Buy" feature which offers enhanced 
capabilities to compare average DRG costs between MTFs and catchment area civilian 
hospitals. The value added for this tool is that it attempts to do a more accurate 
comparison of institutional, rather than professional service component, of the DRG 
cost. What this means is that a CHAMPUS inpatient record actually has two cost 
components an institutional component reflecting the cost of the hospitalization and a 
professional services component reflecting the cost of the "admitting physician". 

However, the MEPRS average inpatient cost has not in the past broken these two 
costs out separately, rather has identified a single average cost which combines the 
two. Through the efforts of NMIMC, the "Make-Buy" feature attempts to correct this 
deficiency so that the civilian average institutional cost per DRG can be compared with 
an MTF average institutional cost per DRG. This takes the professional component 
out of the analysis and offers a truer comparison of institution-to-institution costs. 



25 Jan 94 83 



F. RETROSPECTIVE CASE MIX ANALYSIS SYSTEM . RCMAS is a multi-user 
management information system which supports health care resource analysis and 
utilization management. RCMAS uses Direct Care, Civilian Health and Medical 
Program of the Uniformed Services (CHAMPUS), Uniformed Services Treatment 
Facility (USTF) and Civilian Normative data to provide statistics of observed versus 
expected workload, utilization and cost. A patient level account of cost incurred by 
episode of care can be retrieved from RCMAS, so that you, as a planner, can do a 
detailed cost benefit analysis. Currently, there is no outpatient data for direct care or 
CHAMPUS in RCMAS, therefore the planner will have to use other data sources for 
ambulatory care visits. The following is a list of some of the CHAMPUS costing fields 
that can be found in the RCMAS data system: 

(1) Episode Amount Allowed 

(2) Beneficiary Share Amount 

(3) Billed Amount 

(4) Government Paid Amount 

(5) Other Health Insurance Amount 

(6) Health Care Professional Allowed Amount Total 

(7) Health Care Professional Government Paid Amount Total 

In addition, there are many other costing fields that may or may not be useful 
depending on the type of analysis that the planner is interested in doing. As you 
become more familiar with the RCMAS system you will be able to do a variety of ad 
hoc reports primarily to look at the cost of doing business in-house versus using 
CHAMPUS. 

G. RESOURCE ANALYSIS AND PLANNING SYSTEM (RAPS) . The cost module of 
the RAPS model produces estimates of military health care costs for FY-91 through 
FY-99. Direct and nondirect care cost models are used to translate inpatient and 
outpatient utilization projections into corresponding cost projections. 

Direct care cost projections are estimated using direct care cost models. These 
models were developed from regression analysis of FY-90 Medical Expense and 
Performance Reporting System (MEPRS) data mapped into RAPS clinical services. 
Prior to analysis, the MEPRS cost data were supplemented with estimates of physician 
specialty pay which were not fully reflected in MEPRS. The direct care cost models 
contain estimates of both fixed and marginal cost coefficients. Total cost for each 
beneficiary category equals the sum of the marginal cost coefficients multiplied by the 
respective beneficiary category workload plus the additional fixed cost component. 
Separate direct care costs models exist for stand alone clinics, hospitals, referral 
hospitals, and major medical centers. 



25 Jan 94 84 



Nondirect care costs are estimated from FY-90 CHAM PUS 15-month claims data. 
Both inpatient and outpatient costs models are catchment area specific. They have 
been indexed to US averages, and represent the government costs of care only. 
Inpatient costs were developed from CHAMPUS hospital services and inpatient 
professional services claims data. Inpatient cost models for each catchment/state 
noncatchment area are specified by RAPS clinical service, beneficiary type, and NAS 
status (i.e., NAS required care versus no NAS required care). Outpatient costs were 
developed from the CHAMPUS Cost and Workload Report and Health Care Summary 
Report data. Outpatient cost models for each catchment area are specific by RAPS 
clinical service and beneficiary type. The OCHAMPUS 15-month percentage 
completion rates listed in the table below were utilized to compute inflation factors that 
inflated the 15-month claims data into estimates of 24-month billing cycle utilization. 

The RAPS model produces the following cost reports: 

1. INPATIENT DIRECT CARE COSTS - This report displays inpatient direct 
care costs for the fifteen inpatient clinical areas and four RAPS beneficiary categories. 
Fixed cost estimates are not included in beneficiary cost estimates but are reported 
separately for each clinical area. Costs for inpatient nursery episodes and ambulatory 
obstetrics are included with inpatient obstetrical costs. 



2. INPATIENT NONDIRECT CARE COSTS - This report displays inpatient 
nondirect care costs for fifteen inpatient clinical areas and four RAPS beneficiary 
categories. Three cost reports are generated: NAS-required care, care not requiring 
a NAS, and total nondirect care. Costs for inpatient nursery episodes and ambulatory 
obstetrics are included with inpatient obstetrical costs. 



3. OUTPATIENT DIRECT CARE COSTS - This report displays direct care 
costs for seventeen outpatient clinical areas and four RAPS beneficiary categories. 
Costs for outpatient obstetrics are included with inpatient costs. The user may 
specify that the reported costs for each hospital include the costs for visits performed 
at nearby clinics that are rolled up into the hospital. 



4. OUTPATIENT NONDIRECT CARE COSTS - This report displays outpatient 
nondirect care costs for fourteen outpatient clinical areas and four RAPS beneficiary 
categories. Costs for obstetrics visits are included with inpatient costs. 



25 Jan 94 85 



H. MAKE-BUY ANALYSIS . Make-buy analyses not only require reasonable data 
and methodologies, but need to be done from a rational common sense viewpoint. A 
couple of examples may get the point across. 

- One hospital was considering CHAMPUS recapture by opening up a cardiology 
unit and bringing cardiac catheterization back into the hospital. However, analysis 
showed that many of the recaptured patients would be Medicare eligible. Were these 
procedures to be performed outside the MTF, Medicare would pay for them. If they 
were performed in the MTF, the DoD would pay for them. This clearly would not have 
been a wise business decision. Instead, the hospital CO made arrangements for Navy 
cardiologists to perform cardiac catheterization at a local civilian hospital for much 
more savings to DoD. 

- One hospital made a conscientious decision to reduce its inhouse deliveries and 
have its obstetricians spend more time on gynecological surgery. This was because 
the cost for deliveries in the catchment area was low in comparison with the cost of 
gynecological surgery. Bringing in gynecology at the expense of deliveries made 
good business sense. 



I. CAPITATION BUDGETING . The Military Departments have traditionally 
programmed and budgeted for health programs on the basis of historical consumption 
and workload trends (as described under the Utilization Analysis). A limitation to this 
approach is a built in incentive to produce more services, and thus dis-incentives to 
produce more service, and dis-incentive for more efficient use of resources. 
Capitation is an important strategy for containing health care costs. A modified 
capitation based methodology will be used in Fy-94 for resourcing the Military 
Departments. The changing environment will dictate a change from disease based 
workload measures to a capitation based, population based methodology. The 
military departments will develop their own service - specific methodologies to 
reallocate resources by capitation to the catchment area level. 



The methodology must address O&M (direct care), O&M CHAMPUS, military 
personnel and population. The methodology must be clear to catchment area 
commanders that they are fully responsible for all costs. The commander must 
ensure care is provided in the most cost effective manner (inpatient versus outpatient, 
direct care versus CHAMPUS) to use preventive services, effectively deliver episodes 
of care and carefully monitor volume of services provided. Because capitation 
amounts will be set prospectively, the health care provider can not influence the level 
of funding within the period of allocation. The methodology is population driven, and 
accounts for unique military, medical related functions. It is important to note that the 
modified system is being implemented as a transitional system. The three major 
categories of care include: 

25 Jan 94 86 



(1) Military medical support as composed of non capitated functions, including 
medical readiness not directly related to the size of the force structure. 



(2) Military medical unique capitation rate is additive to the basic capitation rate for 
active duty military personnel. This reflects cost of military medical unique 
functions related to the size of the force structure and service specific 
requirements. 



(3) Medical capitated cost is analogous to the capitation rate used in civilian 
HMOs and similar to rates charged by compelling health care plans under a 
national health care plan. This category includes all costs (MILPERS, O&M 
Direct care and O&M CHAM PUS) associated with providing care, other than 
specific unique requirements for active duty members and military missions 
included in the first and second categories. 



The Defense Health Program (DHP) is responsible for providing a specific benefit 
using military personnel funds and O&M funds of military departments do not provided 
the number of medical personnel originally funded, the DHP can ask the military 
departments to reprogram unused military personnel funds into the DHP operations 
and maintenance to make up the shortage. More detail on the Navy approach to 
capitation budgeting is located in Enclosure (3) - Needs Overview. The concepts of 
health promotion, wellness, and outcome emphasis all fit into the capitation budgeting 
concept. Also, refer to planning Step 5 - Determining Requirements for Services. A 
key level of capitation budgeting is the cost effective delivery os services. The 
applications and uses of manpower standards discussed in this step will assist in 
improving the allocation of scare medical manpower and ensuring effective service 
delivery. One sure consequence of capitation budgeting is that Lead Agent and 
MTFs will have to be more aware than ever of the impact of patients from outside the 
catchment area being treated within catchment area delivery systems. Although under 
current resourcing formulas, the resources expended on noncatchment area residents 
who receive care are built into an MTF's historical base, this may not be true under 
capitation budgeting. Capitation budgeting in a catchment area may be based only on 
the beneficiaries residing in the catchment area. Patients being treated from outside 
the catchment area will have to be identified and resourced separately. The MCQA 
planning reports have the capability to identify these out of catchment area MTF 
patients. 



25 Jan 94 87 



J. OTHER DATA SOURCES . There are many different data sources that can be 
utilized in planning the delivery of health care services. Depending on the type of 
analysis which the planner is conducted will ultimately determine which data source 
would best suit the needs of the planner. In some instances there will be a need to 
unroll MDCs and look at DRGs. Situations will arise where the planner will only need 
to look at visits/depositions at the clinical specialty level with no further detail. This 
manual was not designed to limit the scope or ability of any issues the planner might 
need to solve; therefore, we have included a list of additional data sources and a 
description of what types and kinds of information are contained in them as enclosure 
(2). 



K. SUMMARY . At this point, the following issues should have been dealt with 
relative to the planning issue (1) identification and prioritization of the issues (2) 
identification of the current and future demographics of the population affected, (3) 
analysis of historical and possible future utilization of services, (4) analysis of medical 
need issues relevant to the issue (if available), (5) identification of requirements for 
services in terms of workload and/or personnel necessary to provide the services, and 
(6) identification of the MTFs most cost effective split of workload between MTF and 
other alternative delivery sources. 



25 Jan 94 88 



TAB G - RAPS COST REPORT EXAMPLES 



V 4.50 12/21/92 



RAPS MODEL COST PROJECTION REPORT 
FY99 BASED UPON FY90 BASE YEAR COST 
LONG TERM PERSPECTIVE 



JAN 5, 1994 

11:16:57 

BRAC 11.01 09/22/92 



CLINICAL AREA 



HH TWENTYNINE PALMS 



DIRECT CARE INPATIENT COSTS ($000) 



ACTIVE DEP ACT OTHERS 
DOTY < €5 < 65 OVER 64 FIXED TOTAL 



INTERNAL MEDICINE 


585 


155 


72 


99 


697 


1608 


CARDIOLOGY 




















NEUROLOGY 




















PEDIATRICS 





183 


1 





30 


214 


OTHER MEDICINE 




















GENERAL SURGERY 


229 


146 


32 


24 


457 


888 


ORTHOPEDICS 


564 


40 


11 





264 


879 


ORAL SURGERY 




















OPHTHALMOLOGY 




















OTOLARYNGOLOGY 




















UROLOGY 




















GYNECOLOGY 


66 


390 


32 


6 


229 


723 


OTHER SURGERY 




















OBSTETRICS 


244 


2290 


95 





1659 


4288 


PSYCHIATRY 




















ALL CLINICAL AREAS 


1688 


3204 


243 


129 


3336 


8600 



25 Jan 94 



89 



V 4. SO 12/21/92 



SAPS MODEL COST PROJECTION REPORT 
FY99 BASED UPON PY90 BASE YEAR COST 
LONG TERM PERSPECTIVE 

NH TWENTYNINE PALMS 



JAN 5, 1994 

11: 16 J 57 

BRAC 11.01 09/22/92 



NONDIRECT CARE INPATIENT COSTS ($000) 

CATCHMENT AREAS ONLY 

TOTAL 



CLINICAL AREA 


ACTIVE 
DUTY 


DEP ACT 
< 65 


OTHERS 
< 65 


OVER 64 


TOTAL 


INTERNAL MEDICINE 





282 


133 


58 


473 


CARDIOLOGY 





54 


210 





264 


NEUROLOGY 





12 


2 





14 


PEDIATRICS 





477 


8 





485 


OTHER MEDICINE 





147 


120 





267 


GENERAL SURGERY 





375 


63 


27 


465 


ORTHOPEDICS 





285 


27 


1 


313 


ORAL SURGERY 

















OPHTHALMOLOGY 





8 








8 


OTOLARYNGOLOGY 





8 


19 


2 


29 


UROLOGY 





46 


57 


4 


107 


GYNECOLOGY 





142 


7 


3 


152 


OTHER SURGERY 





482 


129 


18 


629 


OBSTETRICS 





2902 


75 





2977 


PSYCHIATRY 





1871 


268 





2139 


ALL CLINICAL AREAS 





7091 


1118 


113 


8322 



25 Jan 94 



90 



V 4.50 12/21/92 



RAPS MODEL COST PROJECTION REPORT 
FY99 BASED UPON PY90 BASE YEAR COST 
LONG TERM PERSPECTIVE 



JAN 5, 1994 

11:16:57 

BRAC 11.01 09/22/92 



NH TWENTYNINE PALHS 



DIRECT CARE OUTPATIENT COSTS ($000) (WITH ROLLUP) 



CLINICAL AREA 



ACTIVE DEP ACT OTHERS 
DUTY < 65 < 65 OVER 64 



FIXED 



TOTAL 



*~*~™ *~ ™ "* ™ ^ ™ ™»™«*»«*™ va»a * 


•^^^^^^ w 


M- M _^«»^ MM 


""■* "•^ 


WMHMH M 






INTERNAL MEDICINE 


55 


59 


80 


29 


245 


468 


FAM PRAC/PRIM CARE 


5158 


954 


160 


34 


1562 


7868 


FLIGHT/UNDERSEAS MED 




















PEDIATRICS 





511 


7 





221 


739 


ALLERGY 




















CARDIOLOGY 




















DERMATOLOGY 





1 








31 


32 


NEUROLOGY 




















EMERGENCY MEDICINE 


948 


1701 


108 


39 


1228 


4024 


GENERAL SURGERY 


135 


89 


26 


10 


204 


464 


ORTHOPEDICS 


314 


47 


9 


3 


209 


582 


OPHTHALMOLOGY 




















OTOLARYNGOLOGY 




















UROLOGY 




















GYNECOLOGY 


56 


258 


14 


5 


155 


488 


OBSTETRICS 


n/a 


n/a 


n/a 


q/a 


n/a 


n/a 


PSYCHIATRY 


204 


56 


11 


1 


240 


512 


OPTOMETRY 


109 


60 


11 


4 


215 


399 


ALL CLINICAL AREAS 


6979 


3736 


426 


125 


4310 


15576 



25 Jan 94 



91 



V 4.50 12/21/92 



RAPS MODEL COST PROJECTION REPORT 
FY99 BASED UPON FV90 BASE YEAR COST 
LONG TERM PERSPECTIVE 



JAN 5, 1994 

11:16:57 

BRAC 11.01 09/22/92 



NH TWENTYNINE PALMS 



NONDIRECT CARE INPATIENT COSTS ($000) 

CATCHMENT AREAS ONLY 

NAS REQUIRED 





ACTIVE 


DEP ACT 


OTHERS 






CLINICAL AREA 


DUTY 



< 65 
277 


< 65 
119 


OVER 64 
58 


TOTAL 


INTERNAL MEDICINE 


454 


CARDIOLOGY 





54 


164 





218 


NEUROLOGY 





10 


1 





11 


PEDIATRICS 





329 


6 





335 


OTHER MEDICINE 





124 


61 





185 


GENERAL SURGERY 





95 


41 


5 


141 


ORTHOPEDICS 





285 


15 


1 


301 


ORAL SURGERY 

















OPHTHALMOLOGY 





8 








8 


OTOLARYNGOLOGY 





8 


9 


2 


19 


UROLOGY 





46 


57 


4 


107 


GYNECOLOGY 





126 


7 


3 


136 


OTHER SURGERY 





455 


116 





571 


OBSTETRICS 





2899 


75 





2974 


PSYCHIATRY 





1736 


139 





1875 


ALL CLINICAL AREAS 





6452 


810 


73 


7335 



25 Jan 94 



92 



SECTION VIII - BEGIN PLAN DEVELOPMENT 



A. INTRODUCTION . The planning process and steps discussed so far have been 
geared towards MTF planning and resource maximization within the catchment area. 
The objective has been to determine the best resource mix between MTF and 
alternative health care delivery sources for provision of services based upon such 
action as cost comparisons and make-buy methodologies. 

In the planning process, BUM ED has a major policy role to balance, and in a 
sense optimize the system - rather than necessarily optimizing individual components 
of the system. For example, when two MTF's submit plans for OB staffing, the 
CHAMPUS costs for deliveries and gynecological services may be significantly more 
expensive in one case. However, due to certain constraints such as space availability, 
limited staff and/or access to facility may lead BUMED to recommend that the MTF 
utilization the CHAMPUS system. 

In the past, attempts to balance or optimize the system has resulted in some 
efforts at the margins (not marginal efforts). Most notable was the development of 
Clinical Specialty Plans in 1991, which attempted to redistribute provider manpower 
within specialties based upon DoD manpower standards and the and the availability of 
civilian providers as alternative delivery sources. This process had positive benefits 
and served as a precursor to current planning activities, but did not address 
fundamental levels of specialty mix such as primary care and medical education 
considerations. 



B. CURRENT INITIATIVES AND SYSTEM-WIDE BALANCING AND 
OPTIMIZATION . A number of ongoing and anticipated events are precipitating a move 
toward major system-wide balance and optimization which will affect individual MTF 
planning. This included: 

(1) Shift towards primary care versus specialty care. Navy Medicine is moving 
towards the increased use of uniformed clinicians in providing primary care. This shift 
was recently emphasized in the FY-94 Graduate Medical Education Selection Board 
which filled almost one third of its slots with applicants in primary care specialties. 

(2) BRAC Process. The Brae Process will offer unprecedented opportunity to 
balance our system aimed closures and realignment, and to place our uniformed 
providers in support of the line navy in its areas of greatest concentration. 



25 Jan 94 93 



(3) The Center for Naval Analysis (CNA) Force Downsizing Studies and 
Congressionally Directed 733 Medical Force Study. Navy Medicine has been working 
with CNA to develop a computerized planning tool which link changes in Navy Medical 
force structure. In addition a congressionally directed study of the Military health care 
system (733 Study) is looking at major changes in both the wartime and peacetime 
military medical structures. 

(4) Increased emphasis on peacetime operational support and readiness as 
linchpins of Navy medicine. In strategic planning and preparation for POM 96, it is 
clear that Navy medicine must better define its mission in support of our operational 
forces as the reason for our existence. 

All of these system wide issues will affect the resources which BUMED receives 
and planning for the distribution of those resources. In other words BUMED policy 
planning will have to recognize and be responsive to MTF planning. At the same time 
the MTF's may be required to plan or alter existing plans in response to BUMED 
guidance which reflects system wide optimization issues. However, in either case the 
planning process and steps discussed earlier would still apply. 



25 Jan 94 94 



SECTION IX - DEVELOP ALTERNATIVE DELIVERY STRATEGIES 



A. INTRODUCTION . The development of alternative delivery strategies is, in 
essence, the development of a business plan or plan of action. It is based on a 
synthesis of MTF based planning with the corporate policy guidance discussed in 
section VIII. For example, the MTF may have come up with its optimal mix of 
allocating health care services and alternative delivery sources. However, if corporate 
policy issues such as BRAC or downsizing do not provide all the blue-suitors to 
optimize the MTF's local plan, then alternatives must be developed. 



B. BUSINESS PLANS . The Navy hospitals do not currently have a single 
business plan format. However, many hospitals have undertaken the independent 
development of a business plan framework, which includes many of the elements 
discussed in the planning framework and includes most components of a business 
plan found in planning literature. The following outline and explanation of a business 
plan development is currently being used at Naval Hospital Portsmouth to guide their 
identification, analysis and selection of health care delivery. 



TRICARE BUSINESS PLAN 



Philosophy 

The business of providing health care in the nation, in the Department of 
Defense, and in the Tidewater area has changed. Dollars are in short supply and will 
be shorter in the future. There is one "pot" of a finite amount of money available to 
fund a vast amount of needed services. Various scared cows used in the past are 
no longer adequate justification for expenditures. Value added for the entire 
catchment area brought by changes to any given process is the measure of success. 
The value added must be carefully documented in an organized and systematic 
method using data to drive decisions. 

The Tricare Business Plan follows the principles of Total Quality Leadership. Fact 
based decisions can be defended, where as not arbitrary nor capricious. Without 
fact based analysis there will be appearances of favoritism which can not be 
defended. 



25 Jan 94 95 



TRICARE BUSINESS PLAN 

I. EXECUTIVE SUMMARY 

Purpose : Describe briefly in narrative form the proposed project and highlights of 
the various sections. Details should be found in the individual sections. 

A. PROJECT DESCRIPTION STATEMENT -- In a short paragraph describe what 
is it you want to do. 

B. DESCRIBE THE DEPARTMENT/SERVICE -- The project will be within or 
monitored by an existing department. This section briefly describes the 
significant highlights of the department. 

1. CURRENT STAFF 

2. CURRENT WORKLOAD 

3. CURRENT COSTS (i.e., OPTAR, COST/VST, COST/ADM) 

C. CHANGE IN SERVICES OFFERED -- Describe why the project is needed, why 
it will be successful, and how it will impact cost, quality and access. 

1 . WHY WILL THIS PROJECT BE SUCCESSFUL 

2. IMPACT ON COST, QUALITY & ACCESS 

D. COMPETITION PROVIDING SERVICES -- Describe briefly the various ways the 
proposed service is now provided. 

1. CHAMPUS 

2. OTHER DIRECT CARE SITES 

3. SUPPLEMENTAL CARE 

E. TARGET POPULATION OF NEW SERVICE -- For whom will the project 
provide services? What will be the mix? 

F. PROJECTED WORKLOAD WITH NEW SERVICE -- Briefly describe the salient 
points regarding the expected workload as a result of the project and how the 
project may affect CHAMPUS, the network and the direct care system. 

1. IMPACT ON CHAMPUS 

2. IMPACT ON NETWORK 

3. IMPACT ON DIRECT CARE 



25 Jan 94 96 



G. PERSONNEL REQUIREMENTS -- State the additional personnel required. 
Justification as well as evaluation of the various ways of obtaining personnel 
will be placed in the appropriate section. 

1. REQUEST PERSONNEL SUPPORT 

H. FINANCIAL REQUIREMENTS/OFFSETS -- Briefly state the financial 

requirements and impact of the proposed project and when the anticipated 
break even point will occur. If other sources of funds will be used so state. 

1. FIRST FY STAFF 

2. 2ND FY 

3. BREAK EVEN 

I. PERFORMANCE MEASUREMENTS AND MILESTONES LEADING TO 
IMPLEMENTATION - A brief statement on how the project will be judged 
should be included. Again details should be in the appropriate section. 

II. Functional Area Strategic Plan 

Purpose : This section is where the project is placed in perspective to the industry 
and the MFT. 

A. INDUSTRY ANALYSIS (TRICARE AIDED) - Tricare has data on the Tidewater 
area and will help in this area. 

1. GROWTH OF AREA 

2. HEALTH CARE IN TIDEWATER 

a. NORTH SIDE 

b. SOUTH SIDE 

3. CLINICAL INFLUENCES -- There may be changes in the practice of 
medicine which will affected the proposed project. This would be where 
such changes would be addressed. The providers sponsoring the project 
will be the best source of this information. 

4. TECHNOLOGICAL CHANGE -- There may be changes in technology 
which will affect the project. There may be changes on the horizon which 
would suggest not to pursue the project. The providers sponsoring the 
project will be the best source of this information. 



25 Jan 94 97 



B. MTF ANALYSIS -- This section describes the MTF interms of mission, 

population supported, workload, and costs, and costs in general. Again this is 
to help put the project in perspective. 

1. OBJECTIVE (MISSION) -- The mission statement from the command 
organization manual with some modifications could serve here. 



2. DoD POPULATION PROJECTIONS/HISTORICAL « DMIS data or data 
Tricare Ops has could be placed here. Significant historical shifts should 
be defined. 

3. HISTORICAL, CLINICAL SERVICE SPECIFIC, CHAMPUS & DIRECT CARE 

- The clinical service data should be highly aggregated such as on the 
MEPRS report. There should not be much detail in this section. 

a. WORKLOAD 

(1) ADMISSIONS 

(2) OCCUPIED BED DAYS 

(3) OUTPATIENT VISITS COST 

b. COST 

(1) ADMISSIONS 

(2) OCCUPIED BED DAYS 

(3) OUTPATIENT VISITS 

III. Functional Activity Strategic Plan 

Purpose : This sections focuses in on the particular department or clinic sponsoring 
or implementing the proposed projects. This is where the detail begins to 
take shape, 

A. DEPARTMENT RELATIONSHIP - What is the mission of the department and 
how does the department's mission fit into the mission of the command. Are 
there relationships outside of the command. Describe how the project fits 
and supports the department's mission. 

B. EVENTS AFFECTING DEPARTMENT'S DEVELOPMENT - Are there significant 
events which affected the development of the department which will help 
someone understand changes in data presented below. 



25 Jan 94 98 



C. CURRENT ORGANIZATIONAL STRUCTURE -- The department or clinic should 
be described so existing resources can be reviewed. Tables would be 
appropriated with narrative pointing out items of specific interest and areas 
investigated and things discovered resulting from these investigations. If there 
is a gap between the billets assigned and the bodies on board, what is the 
likelihood there will be filled? 

1. ORGANIZATION CHART 

2. CURRENT PERSONNEL - CIVILIAN AND MILITARY TRICARE PLAN 

3. BILLETS AUTHORIZED 

4. BODIES ON BOARD 

5. UTILIZATION OF SPECIALTY PERSONNEL 

6. CONTRACT, PARTNERS, OTHERS 

7. STATUS OF CURRENT SYSTEMS 

D. HISTORICAL TRENDS -- Tables outlining the various pieces of information 
over time would be appropriate with comments on important variances. 

1 . STAFFING -- Has there been a chronic shortage of inability to hire or staff 
certain positions, and why? What was done to fill these positions? 

2. MTF WORKLOAD 

a. INPATIENT ADMISSIONS/OCCUPIED BED DAYS 





b. OUTPATIENT 




C PARTNERSHIP WORKLOAD 


3. 


CHAMPUS 




a. INPATIENT 




b. OUTPATIENT 




c. COSTS 


4. 


NASs 



E. FORECAST WITHOUT CHANGE -- What would happen without implementing 
the proposed project. This will help build the base for developingand 
evaluation plan later. 

1. STAFFING 

2. MTF WORKLOAD 

a. INPATIENT ADMISSIONS/OCCUPIED BED DAYS 

b. OUTPATIENT 

c. PARTNERSHIP WORKLOAD 



25 Jan 94 99 



3. CHAMPUS 

a. INPATIENT 

b. OUTPATIENT 

c. COSTS 

F. CURRENT PATIENT MIX - Describe how patients are directed to the 
department or clinic now. Describe the demographics of the patient 
population. Graphs and charts would be appropriate. This will serve to help 
develop your recapture and evaluation plan. 

1. REFERRALS 

2. DIRECT APPOINTMENTS 

3. STATUS 

a. ACTIVE DUTY 

b. DEPENDENT ACTIVE DUTY 

c. RETIRED 

d. DEPENDENT OF RETIRED 

e. MEDICARE ELIGIBLE 

G. CURRENT CAPACITY - Describe the capacity of the department or clinic. 
What are the current limiting factors preventing the department from fully 
achieving its mission. This will help define resources required for the project. 
The project then will address each limitation and describe how they will be met 
in a later section. 

1. SPACE LIMITING 

2. STAFF LIMITING 

3. EQUIPMENT LIMITING 

4. OTHER LIMITING FACTORS 

IV. Proposed Functional Activity Improvement Program - this is the section where the 
propose project gets fully developed and evaluated. 

A. ASSUMPTIONS -- State all assumptions used in developing and evaluating the 
project. 

B. DESCRIBE PROPOSED PROJECT -- State what will be required to implement 
the project and how existing limitations (described above) will be handed. 

a. FINANCIAL 

b. STAFFING 

c. EQUIPMENT 

d. MATERIALS & SUPPLIES 

e. PROCESS 

f. FACILITIES 

25 Jan 94 100 



2. MTF AVAILABLE RESOURCES TO SUPPORT PROPOSED PROJECT -- 
State if the MTF will support any portion of the project in any manner. 

a. FINANCIAL 

b. STAFFING 

c. EQUIPMENT 

d. MATERIALS & SUPPLIES 

e. PROCESS 

f. FACILITIES 

3. EXPECTED RETURN/BENEFITS -- Describe what will be the expected 
return/benefits because of the implementation of the project. Both 
quantifiable and qualitative impacts should be addressed. 

a. OUTPATIENT VISITS 

(1) DIRECT CARE 

(2) CHAMPUS 

b. ADMISSIONS 

(1) DIRECT CARE 

(2) CHAMPUS 

c. OCCUPIED BED DAYS 

(1) DIRECT CARE 

(2) CHAMPUS 

d. OTHER MEASURES 

e. LINE MILITARY MISSION 

f. THIRD PARTY REIMBURSEMENT OFFSETS - Will there be a significant 
increase in income form 3rd parties to help offset expenses of the 
project? 

4. PERFORMANCE MEASUREMENTS AND MILESTONES LEADING TO 
IMPLEMENTATION (POA&M) -- Since it will take time to implement the 
project what are the steps to full implementation. This will help to provide 
indications early in the project if problems exist phasing plan will help 
schedule transfer of funds to the MTF. 

a. TIME TABLE OF MILESTONES 

(1) PROCUREMENT OF EQUIPMENT 

(2) FACILITY MODIFICATIONS 

(3) STAFFING 

{4) CONTRACT, PARTNERSHIP PROGRESS 

b. FORECAST OF WORKLOAD 

c. EXPENDITURE PLAN (PHASED) 

25 Jan 94 101 



d. UTILIZATION MANAGEMENT 

5. IMPACT OF PROPOSED PROJECT -- The stated goals of Tricare are 
improved access to quality health care while controlling costs. Therefore 
every project needs to be evaluated based on these three areas. That is the 
purpose of this section. It will be the first (and maybe only) section reviewed 
by auditors. 

a. COST OF CARE 

b. QUALITY OF CARE 

c. ACCESS TO CARE 

C. TARGET MARKET -- Describe who the project will attempt to affect. 

1. SCOPE -- Where will patients come from. 

a. MTF CATCHMENT 

b. PENINSULA/SOUTHSIDE 

c. REGIONAL 

2. DEFINE TARGET MARKET - Describe the characteristics of the target 

market. 

a. CHARACTERISTICS 

(1) SPONSOR STATUS 

(2) AGE 

(3) SEX 

b. REFERRALS 

c. DIRECT APPOINTMENTS 

3. SENSITIVITY TO RECAPTURE -- Describe why this group of people can 
be brought into the project. 

4. MARKETING - PLAN HOW TO CAPTURE WORKLOAD -- This is where 
you spell out just how you will ensure the success of the project by getting 
the patients into the new service without bringing those you do not want to 

bring. 

D. INTERFACES -- It is important to consider how the proposed project will affect 
other departments, other clinics, other MTFs, the network of civilian providers, 
and the community. It would be unwise to have a project which would 
adversely affect any one of these groups without carefully weighing the costs 
and benefits. 



25 Jan 94 102 



1. WITH YOUR MTF 

2. WITH OTHER MTFS 

3. WITH TRICARE NETWORK - PPO, HMO (FUTURE) 

4. WITH NON-NETWORK 

V. Functional Activity Performance Targets and Measures - This is the section which 
begins to lay out the evaluation plan. Describe what things will be measured to 
know if the project is successful and what operating targets are established for the 
project. 

A. DESCRIPTION OF MEASURES 

B. TARGETS 

VI. Evaluation Plan -- Describe how you will know if the project is a success. The 
plan LT Butler presented could serve as a blueprint for this section. 

VII. Economic Analysis of Proposed Process 



25 Jan 94 103 



STANDARD OPERATING PROCEDURES 

FOR 

TR1CARE PROJECTS 



INITIATING TRICARE PROJECT ANALYSIS : 

1 . Director for Resources (DFR) receives project brief from Director, Managed Care 
(DMC), with the following included: 

a. All changes from the current program 

b. New personnel requirements 

c. New equipment purchases and/or leasing requirements 

d. Supply requirements 

e. Departments or services involved 

COLLECTION OF WORKLOAD AND COST : 

1 . Forms used to collect Cost and Workload are requested from Progress 
Reports and Statistics Division. The following information is due to Resources 
Management Division within 2 weeks. 

a. The Composite Institutional Record (CIR) form, used to request the MCQA 
CHAMPUS catchment area inpatient workload. 

b. The Composite Professional Services Record (CPR) form, used to request 
MCQA CHAMPUS catchment area outpatient visits. 

c. The TRICARE Recapture Project worksheet used to request MEPRS data. 

2. Market Surveys will be initiated and completed by the manage care and are 
due to Resources Management Division within 1 week, as follows: 

a. Use three outside sources (Attachment 1) concerning salary information 
and using the form provided by the Contracting Office (Attachment 2). 

b. Forward Market Surveys to applicable department head for review. 

c. If the personnel are determined to be contractual hires submit the Market 
Surveys with the project, to the Contracting Office. 

3. Contractual pay caps for contract personnel are completed by the Contracting 
Administration, Code 0207.1 and are due to Resources Management Division 
within 1 week, as follows: 

25 Jan 94 104 



a. Submit a memo to the Contracting Office, Code 0207.1 for Contractual 
pay caps for the personnel involved. 

Request the Budget Division provide the following costs to the Resources 
Management Division within 1 week. 

a. Supplemental Care Cost involved in project. 

b. GS pay scale plus fringe benefits for direct hire personnel 



ANALYSIS OF PROJECT DATA : 

1 . The following project parameters must be identified: 

a. Review the MEPRS data 

b. Lists the catchment areas involved. 

c. Review the number of inpatient admissions and associated total 
government cost from MCQA. 

d. Review the number of outpatient visits and associated total government 
cost from MCQA. 

e. List the patient categories that are involved. 

2. Data Elements entered on the CHAMPUS worksheet analysis areas follows: 

a. Variable cost per admission with pharmacy costs 

b. Variable costs per outpatient visits (OPV) without pharmacy costs. 

c. Establish the percent of projected number of admissions by patient 
category (number of units are automatically produced). 

d. Establish the percent of projected number of OPVs by patient category 
(number of units are automatically produced). 

3. Determining supply and equipment requirements are as follows: 

a. Supply Costs = Direct variable cost for supplies times projected units. 

b. Equipment requirements. 

c. Other Costs (ancillary) = Average variable cost of the ancillary services 
times the number of projected units. 

4. Creating itemized exhibits for the following: 

a. Personnel costs: 

(1) Direct hire personnel 

25 Jan 94 105 



(2) Contract personnel 

(3) Mix of direct hire and contractual, if necessary 

b. Supply and Equipment. 
5. DFR reviews completed costs analysis, 
a. Make any revisions. 



25 Jan 94 106 



PREPARATION OF BUSINESS PLAN 

1. The Business Plan must be provided as follows: 

a. Part I - Executive Summary. 

b. Part II - Functional Area Strategic Plan 

c. Part III - Functional Activity Strategic Plan. 

d. Part IV - Functional Activity Improvement Program. 

e. Part V - Evaluation Plan. 

f. Part VI - Economic Analysis of Proposed Process. 

2. DFR reviews Business Plan 

FINAL REVIEWS/PRESENTATIONS TO THE DFR AND PMC 

a. Review by Contracting Office. 

b. Presentation to the DFR and DMC. 

c. DFR/DMC review with the department head. 

d. DMC/DFR presentation to the TRICARE project board. 

e. DMC presentation to the Board of Directors. 

f. DMC presentation to the TRICARE Commanders board. 



25 Jan 94 107 



ENCLOSURE ONE 



MED-81 
HEALTH CARE PLANNERS 



MED NAME 



E-MAIL 



TELEPHONE 



81 Mr. John Durham 

Head, Strategic Planning 

81 S Ms. Angela Roderick 
Secretary 

811 CDR D. LeDonne NC 

Deputy, Strategic Planning 

813 Dr. Sandra Mayo 
Health Systems Specialist 

814 Ms. Freda King 
Management Analyst 



nmc9jrd@bumed40 
nmc2amr@bumed10 
nmc2dml@bumed10 
nmc8sbm@bumed20 

nmc2fck@bumed10 



(202) 6530230 
(A) 294-0230 

(202) 653-1860 
(A) 294-1860 

(202)6530223 
(A) 294-0223 

(202) 6530175 
(A) 294-0175 

(202) 6530245 
(A) 294-0245 



Enclosure (1) 



ENCLOSURE TWO 



SUMMARIZATION OF MILITARY MEDICAL INFORMATION SOURCES 



mpmv$y&rm name " 


JNFORMATIOK PBOVfpep. 


HOW ACCSSSEO 


Poc 


Standard Element Activity Reporting System (SEARS) 


Navy MTF Data (Admissions, OBDs, 
Visits, NASs, NAVCARE visits, ALOS, 
Operating Beds, Occupancy Rate, 
Births, ADPL, AWUs, IWUs, Weighted 
Ancillary Services) 


Hard Copy Report 
(Updated Monthly) 


NMIMC Bethesda 
(301) 295-2410 

* Call to be added 
to distribution 


Facility Report of Inpatient Services/Biometrics (FRISB) 


Navy MTF Data (Dispositions by Work- 
center, Total Beddays, Cooperative 
Care Days, Supplemental Care Days, 
ICU Days, Bassinet Days. Top 20 
Diagnoses & Procedures) 


Hard Copy Report 
(Updated Monthly) 


NMIMC Bethesda 
(301)295-2410 

* Call to be added 

to distribution 


Navy Health Care Planning Matrix (HCPM) 


Navy MTF Data (Construction Year, 
Operating Stats, Inpatient Stats, 
Ancillary Services Stats, Outpatient 
Stats, Other Navy Clinic Stats, Key 
Staffing Stats, Budget Data, 
Population Estimates, CHAMPUS In- 
patient Stats, CHAMPUS Outpatient 
Stats, Top 5 CHAMPUS Clinic Services, 
Area VA/Civilian Hospitals, Area 
Civilian Physicians, Mobilization Stats) 


Hard Copy Report 
(Updated Annually) 


NMIMC Bethesda 
(301) 295-6202 

* Call to be added 
to distribution 


Executive Information System (EIS) 


Navy MTF Data (EIS provides decision 
support info to Navy Healthcare Exec- 
utives, analysts and facility managers 
who determine Navy medicine's ability 
to meet stated goals. Extracts data 
from multiple NMIMC systems and 
provides a single source of info con- 
cerning all aspects of health care — 
Current/Future Modules: Health Care 
Planning, Human Resources, Education 
& Training. Health Care Support Opera- 
tional Forces, Health Care thru Fixed 
Facilities, Quality Assurance, Manage 
Finances, Information Resources, 
Administrative Services, Procurement/ 
Contracting, Physical Resources, R&D) 


NMIMC Mainframe 
(Acess via modem 
orMED-OAIink) 

* MED -OA preferred 

(Updated monthly) 


NMIMC Bethesda 

(301) 295-0419 

* Call for access 
ID & password 



RKPORT/SYSTEM NAME 


INFORMATION PROVIDED 


HOW ACCESSED 


POC 


Defense Medical Information System (DMIS) Data: DMIS Product 


DoD Data (DMIS data can be accessed 
via a menu -driven system, or by using 
SQL queries — provides historical 
data for beneficiary populations, facilities, 
direct care costs/workload, CHAMPUS 
costs/workload and other aspects of 
health care delivery. Data organized with 
respect to facility catchment areas and 
non -catchment areas of each state/ 
country) 


Ft Detrick Mainframe 
(Access via modem 
orDDN link) 


DMIS Info Center 
1-800-627-DMIS 

* Call for access 
ID & password 

OASD(HSO-RAMS) 
(703)756-1123 


Resource Analysis & Planning System (RAPS): DMIS Product 

* Note: For BRAC III planning, MED-81/B2 developed a 
"Migration Model" that incorporates RAPS model methodology 
coupled with macro-driven linked LOTUS spreadsheets. 


DoD population, utilization, cost and 
workload projections (Developed to pro- 
vide military health care analysts with an 
automated tool to help assess the impact 
of various factors on the peacetime de- 
livery of healthcare: excellent tool for 
conducting "WHAT IF?" analyses) 


Ft Detrick Mainframe 
(Access via modem 
orDDN link) 


DMIS info Center 
1-800-627-DMIS 

* Call for access 
ID & password 

OASD(HSO-OMS) 
(703) 756-8910 


Retrospective Case Mix Analysis System (RCMAS): DMIS Product 

* Notes: The previous system, RCMAS-P (Proprietary) has 
been replaced by RCMAS -OSE (Open System Environment). 

There is a RCMAS-Central for use by OASD(HA), the Surgeons 
General, etc. There is also a RCMAS-Local for use by individual 
MTFs. 

The new information system known as the Military Health Care 
Management Information System (MHCMIS) will be coming on- 
line at various locations soon — its proliferation schedule will 
parallel that of CHCS. MHCMIS will have RCMAS-OSE as 
one of its components. 


RCMAS is a management information 
system which provides a capability to easily 
and quickly perform inpatient health care 
utilization analyses that support health 
care management decision making. 
RCMAS incorporates data from a 
number of sources. Only system with the 
capability to perform analyses across USTF, 
direct care & CHAMPUS while simultan- 
eously comparing multiple civilian and 
DoD normative sources. 


Ft Detrick Mainframe 
(Access via modem 
orDDN link) 


DMIS Info Center 
1-800-627-DMIS 

Navy Functional 

Proponent: Mr. Joe 
Goodin (BUMED-13) 
(202) 653-1391 

* Call for training 
(Access ID & password 
received @ training) 

OASD(HSO-RAMS) 
(703) 756-1123 


MICRO-DMIS: DMIS Product 


DoD Data (PC— based system that displays 
facility-level, monthly workload, NAS and 
facility data by beneficiary category and 
allows comparitive displays over a wide 
variety of aggregations — e.g., Service 
Branch, DoD Region. Provides graphic 
and tabular displays which can be printed 
or plotted as desired. Allows selection of 
facility -level data based on specified 
search criteria) 


PC -based 
(Update diskettes 
received monthly) 


DMIS Info Center 
1-800-627-DMIS 

* Call to be added 
to distribution 

OASD(HSO-RAMS) 
(703) 756-1123 



REPORT/SYSTEM NAME^^^^^^^^^^^^^V 


INFORMATION ■'.PROVIDED; 


HOW ACCESSED 


POC 


CHAMPUS Medical Information System (CMIS) 


CMIS was developed by Maximus Inc. for 
OCHAMPUS, and has subsequently been 
made available to the services for use in 
managing the CHAMPUS component of 
their health care operations. CMIS provides 
data on the cost and workload of CHAMPUS 
care, aggregated by DoD geographical area 
(MTF, catchment area, clinic catchment 
area, or pricing locality), sponsor's branch 
of service, type of care (inpatient or out- 
patient), specialty (MDC, DRQ, medical 
specialty, or provider specialty), and other 
measures. Data are provided monthly but 
are projected to completion for the fiscal 
year. 


Currently, Navy does 

not have a platform 

for CMIS. We are 

using the Army SG 

system. 

(Access via modem) 

Navy system will 
soon be available 
via NMIMC. 


Navy CMIS POC: 
Mr. Greg Atkinson 
(202) 653-0276 

* Call for access 
ID & password 

OCHAMPUS POC: 
Mr. Rich Barnett 
(303) 361-1006 

Maximus Inc. POC: 
Mr. Rich Keiser 
(703). 734-4200 


Managed Care Query Application (MCQA) 

* Notes: MED-61 has coordinated with NMIMC to have a section 
of fixed "BUMED Planning Reports" added to the MCQA. 

The outpatient report maps CHAMPUS outpatient workload into 
MEPRS outpatient categories based on the provider specialty 
code on the CHAMPUS claim. This gives a more "apples to 
apples" comparison between direct care/CHAMPUS allowing iden- 
tification of outpatient market share by specialty. 

The inpatient report provides direct care & CHAMPUS dispositions 
by MDC. age, sex & beneficiary category. It also indicates 
dispositions of patients from outside the catchment area. 


MCQA provides access to the Navy 
Inpatient Biometrics data fields that exist 
on the Standard Inpatient Data Record 
(SIDR) — data on Navy direct care 
inpatient workload. 

MCQA also provides access to CHAMPUS 
cost and workload data generated by the 
Tri-Service CHAMPUS Statistical Database 
Project — key to this project is the trans- 
formation of fragmented adjudicated claims 
data into an episode of care format. Also, 
provides a CHAMPUS Provider File. 


NMIMC Mainframe 
(Access via MED-OA 
link or modem) 

* MED-OA preferred 


NMIMC Bethesda 
(301) 295-0868 

* Call for access 
ID & password 


CHAMPUS Cost & Workload Report 


CHAMPUS report by service branch, 
category of beneficiary, and type of care 
(delivery, psychiatric, medical, surgical). 
Data available for all care, including ad- 
junctive dental, drugs, and program for the 
handicapped. 


Microfiche 
(Produced quarterly) 


OCHAMPUS 
(303) 361 -8806 

* Call to be added 
to distribution 


Nonavailability Statement Report 


Report summarizes cost& utilization data 
by clinical specialty and category of ben- 
eficiary for comparison with NAS issuances. 


Microfiche 
(Produced quarterly) 


OCHAMPUS 
(303) 361 -8806 

* Call to be added 
to distribution 


Partnership Summary Report 


Summary of partnership cost/utilization data 
by catchment area and clinical specialty. 


Microfiche & 
Hard Copy Report 
(Produced quarterly 
+ 24- month FY 
report) 


OCHAMPUS 
(303) 361 -8806 

* Call to be added 
to distribution 



; rhpor^sVstcmname^^^^::.^:: ; ' .■ 


INFORMATION PROVIDED 


HOW ACCESSED 


PQC 


Partnership Procedure Code Data Report 


Summary of partnership procedure code 
data by provider specialty and catchment 

area. 


Microfiche 
(Produced quarterly 
+ 24 -month FY 
report) 


OCHAMPUS 
(303) 361 -8806 

* Call to be added 
to distribution 


Partnership Provider Summary Report 


Summary of partnership cost/utilization data 
by provider. 


Microfiche 
(15- month & 24- 
month FY reports) 


OCHAMPUS 
(303) 361 -8806 

* Call to be added 
to distribution 


CHAMPUS Provider Participation Report # 1 


Provides individual provider participation 
rates by specialty of provider by MTF 
inpatient catchment area and state — i.e., 
providers who accepted CHAMPUS assign- 
ment. 


Microfiche 

(2X yearly per FY) 


OCHAMPUS 
(303) 361 -8806 

* Call to be added 
to distribution 


CHAMPUS Provider Participation Report # 2 


Provides CHAMPUS professional provider 
participation rates by provider specialty 
for each state and MTF inpatient catchment 
area. 


Microfiche 
(Quarterly & FY) 


OCHAMPUS 
(303) 361 -8806 . 

* Call to be added 

to distribution 


CHAMPUS Health Care Summary Report 


Provides CHAMPUS cost & utilization data 
by catchment area and category of care. 
Outpatient drug, program for the handi- 
capped and adjunctive dental care data 
are not reported. No breakouts by branch of 
service, and only partial breakouts by 
beneficiary category. 


Microfiche & 
Hard Copy Report 
(Produced quarterly) 


OCHAMPUS 
(303) 361 -8806 

* Call to be added 
to distribution 


CHAMPUS CPT-4 Procedure Code Report 


Cost/utilization data for inpatient MHSS catch- 
ment areas. Data includes professional ser- 
vices data for inpatient, outpatient and com- 
bined procedures. Data available only for all 
provider specialties combined. 


Hard Copy Report 
(Fiscal year only 
with a 15 or 24- 
month collection 
period) 


OCHAMPUS 
(303) 361 -8806 

* Available by special 
request only 


CHAMPUS Ready Access Information System (CRAiS) 


Provides the CHAMPUS Maximum Allowable 
Charge (CMAC) by zip code for each 
CPT-4 code. Also, allows the user to per- 
form automated searches of the CHAMPUS 
Policy Manuals. 


CD-ROM 
(Those on distribu- 
tion list receive 
periodic updates) 


OCHAMPUS 
(303) 361 -8806 

* Call to be added 
to distribution 


Quick Response Data File (QRDF) 


Full FIDCRS format of CHAMPUS claims 
data. 


Difficult to access. 
Some personnel 
have knowledge on 
how to write COBOL 
code to extract de- 
sired data. If a QRDF 
query is needed, 
contact NMIMC. 


NMIMC Bethesda 
(301) 295-1216 

* Call to request QRDF 
queries. 



REPORT/SYSTEM NAME 


INFORMATION: PROVIDED . 


HOW ACCESSED 

Hard Copy Report 
(Those on distribu- 
tion list receive 
periodic updates) 


POC 


Catchment Area Directory 


Provides a listing of what zip codes comprise 
the various catchment areas. 


OASD(Hsb-RAMS) 
(703) 756-1123 

* Caii to be added 
to distribution 


BilletfBody Database 


Provides detailed billet/body data for all 
Navy activities. Billetfbody files are available 
by corps. Data extracted monthly from the 
BUPERS Total Forces Manpower Manage- 
ment System (TFMMS). 


NMIMC Mainframe 
(Access via MED-OA 
link) 


NMIMC Bethesda 
(301) 295-0809 

* Call for access 
ID & password 


Medical Expenses Performance Reporting System (MEPRS) 


Standard Personnel Management System 
(SPMS), Worldwide Outpatient Reporting 
System (WORS), Expense Assignment System 
(EAS) ver Ell, Automated Quality of Care 
Evaluation Support System (AQCESS), 
Composite Health Care System (CHCS), 
Integrated Disbursing & Accounting Resource 
Management System (IDARMS) are all 
"feeder" systems to MEPRS -- they 
provide other information as well, but for 
MEPRS, SPMS provides labor expenses, 
WORS provides outpatient workload, 
AQCESS/CHCS provides inpatient workload, 
and IDARMS provides expense data. MEPRS 
is the DoD Cost Allocation System. Inpatient 
data is provided as dispositions & OBDs by 
MEPRS workcenter with the average cost 
per disposition and OBD displayed for that 
workcenter. Outpatient data is provided as 
visits by workcenter with the average cost 
per visit displayed for that workcenter. 


Hard Copy Report 
& NMIMC Mainframe 
(Access via MED-OA 
link) 


NMIMC Bethesda 
(301) 295-0419 

* Call to request hard 
copy reports and to 
get access ID & pass- 
word for mainframe 


Defense Manpower Data Center (DMDC) 


Provides DEERS/retiree population counts. 
Data can be provided by zip code, gender, 
age and beneficiary category. 


BUMED-08 & 
NAVMEDLOGCOM 
have access to 
Mainframe @ Naval 
Postgraduate School, 
Monterey, CA 


BUMED-08 POC: 
LT S chaffer 
(202) 653-1972 
LT Mihara 
(202) 653-0100 

NAVMEDLOGCOM POC: 
Mr. Lawrence Little 
(301) 619-2073 

DMDC POC: 
Mr. Dick Orphin 
(408) 655-0400 



REPORT/SYSTEM NAME; 


INFORMATION PRQVfQED ; ;> 


miivfi!$!®Mi!p 


si^^Siii^SP^i 


Office of Medical/Dental Affairs (OMDA) 


Provides supplemental care information 
on emergency and outcatchmentcare 
rendered to active duty (USN/USMC). 


Submit a request to 
OMDA 


OMDA Great Lakes 
Mr. LeBlanc 
(708) 688-2902 


Standard Personnel Management System (SPMS) 


A Navy Medical Department Automated 
Information System (AIS) with the following 
modules; Manpower/Personnel Management, 
MEPRS/Military Labor 3, Education & Training, 
and Medical Personnel Augmentation. 


NMIMC Mainframe 
(Access via MED-OA 
link or modem) 

* MED-OA preferred 


NMIMC Bethesda 
(301) 295-0810 


Temporary Additional Duty (TAD) Database 


A database that tracks Navy Medical Depart- 
ment TAD on an individual basis. 


Contact BUMED for 
a Diskette Copy of the 
database. 


BUMED-312 
(202) 653-0242 


CHAMPUS Catchment Area Billing Report (CABR) 


Tri-Service in & out-catchment (excluding 
CRI) CHAMPUS obligations. 


Hard Copy and 
Diskette Copy 


BUMED-14 
(202) 653-1135 


CHAMPUS Reform Initiative (CRI) Resource Sharing Report 


A report listing all the resource sharing 
agreements that are in existence in the CRI 
areas. 


Hard Copy Report 


BUMED-13 
(202) 653-1645 


Manpower Analysis & Planning System (MAPS) 


Tool used to translate workload (historical, 
current orforecasted) into staffing requirements 


PC-Based 
(Call HA- HSO for 
Documentation and 
Diskettes) 


OASD(HSO-OMS) 
(703)756-8910 

BUMED-15 
(202) 653-1221 


3rd Party Billing: Third Party Outpatient Collection System (TPOCS) 


Amounts billed/collected by CPT-4 procedure 
code. 


Submit request to 
NMIMC 


NMIMC Bethesda 
(301) 295-0419 


Navy Standard Claimancy Accounting Mgmt System (NSCAMS) 


Financial accounting information by MTF 
broken out by AG/SAG, SFC, etc. 


Submit request to 
BUMED-14 


BUMED-14 
(202) 653-1135 


Zip Code Mapping Software 


Software that can provide a graphical map 
picture of a catchment area's population 
densities and/or CHAMPUS expenditures by 
zip code. 


Submit request to 

NMIMC ' 


NMIMC Bethesda 
(301) 295-0819 



Compiled by MED-822, 23 Nov 93 



DMIS Products - Documents 



Catchment Area Directory 

A catchment area is defined as all the 
zip codes with centers 40 miles from 
the center of the MTFs zip code. This 
document provides a list of those zip 
codes, 

Health Data Summary 

Provides a comprehensive overview 
of the operations of the Military Health 
Services Systems(MHSS) for a 
specified fiscal year. It combines data 
from many sources in one document, 

Medical Expense and Performance 
Reporting System (MEPRS) 
Summary Report 

Provides a detailed summary of 
Medical Expense and Performance 
Reporting System (MEPRS) data 
reported to the DMIS by the Services 
for a specified fiscal year. 

This document focuses on MEPRS as 
a uniform system lor collecting, 
processing, and reporting facility-level 
data that describe medical workload, 
expense, and staffing by individual 
work center with the MTF. 



Management Information Summary 
(MIS) 

Provides direct care utilization 
statistics, comparative data, and 
catchment area direct care utilization 
details for all DoD hospitals reported by 
the Service Biometrics Departments. 
Also provides counts of nonavailability 
statements from the DEERS automated 
N AS system. 

Population Report 

Contains several population reports 
which summarize the fiscal year MHSS 
beneficiary population. 

This document contains detailed 
location-specific population reports 
(e.g., a report for each catchment and 
non-catchment area) and provides 
further detail on the definition and 
derivation of these locations. The FY 
population subtotals are displayed by 
beneficiary category, age group, and 
sex; and by beneficiary category and 
sponsor service. 



Nonavailability 
Statement (NAS) 
Summary Report 

Provides detailed 
summary of-NAS 
data reported to the 
DMIS by the 
Services. Pie 
summary includes 
data by facility, 
clinical specialty, 
beneficiary category 
and reason of 
issuance. 

























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DMIS Products - Systems 



DMIS Menu System 

Provides historical data for beneficiary 
populations, facilities, direct care 
costs and workloads, the provision of 
care through civilian sources under 
the CHAMPUS, and other aspects of 
the delivery of health care services. 

Data are organized with respect to 
facility catchment areas (for a hospital, 
this is the area within approximately 
40 miles) and the non- catchment 
areas of each state or country. 

Micro DMIS System 
A PC based system thai displays 
facility-levei, monthly workload, NAS 
and facility data by beneficiary 
category and allows comparative 
displays over a wide variety ol 
aggregations (e.g. Service Branch, 
DoD Region). Provides graphic and 
tabular displays which can be printed 
or plotted as desired. 
Allows selection of 
facility-level data 
based on specified 
search criteria. 

Resource Analysis 
and Planning 
System (RAPS) 
Developed to provide 
military health care 
analysts with an 
automated tool to 
help assess the 
impact of various 
factors on the 
peacetime health 
care delivery system 
Model capabilities 
include a population 
projection option and 
a resource analysis 
option. 



Retrospective Case Mix Analysis 
System (RCMAS) 

Used for strategic planning and 
management analysis of the MTF 
based on the analysis of patient record 
Diagnosis Related Group (DRG) data. 
Individual MTFs and headquarter 
commands benefit from the system's 
analyticalcapabilities. 

Uniformed Service Treatment 
Facility (USTF) 

Used to process accumulated monthly 
submissions on a quarterly basis and 
produce hardcopy management 
reports for use by the USTFs and the 
USTF Program Office. 




DMIS Sources 



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Biometrics 
Offices of the 
Services 

Detailed 
Individualized 
Inpatient Medical 
Treatment Facility 
(MTF) utilization 
data. Includes 
diagnoses, 
procedures, and 
patient 
demographic 
data, as well as, 
quarterly data on 
Nonavailability 
Statements 
(NAS) issued. 



The DMIS maintains a variety of data 
that describe the Defense health 
system in terms that are useful for 
various planning, policy making, and 
program design and evaluation 
activities, These data have been 
selected to characterize facility costs, 
utilization and staffing, as well as, 
catchment area populations and 
Civilian Health and Medical Program 
of the Uniformed Services 
(CHAMPUS) costs and utilization. 

Sources ol DMIS data are: 



Defense Enrollment Eligibility 
Reporting System (DEERS) 

Selected data from the DEERS 
enrollment file for determination of 
catchment area populations, as well as, 
monthly data on NASs issued. 

Office of the Civilian Health and 
Medical Program of the Uniformed 
Services (OCHAMPUS) 

Selected data from individual claims 
records describing the care obtained 
by DoD beneficiaries from the civilian 
sector. 



Medical Expense and Performance 
Reporting System (MEPRS) 

Facility cost, utilization, and staffing 
data within a standardized set of 
functional areas and work centers. 



Uniformed Service Treatment 
Facility System (USTF) 
Patient information for military sponsors 
and dependents who received care at 
Ihe ten USTFs. 



Defense Medical Facilities Office 

(DMFO) 

A wide range of summary data that 
characterizes military hospitals, 
medical and dental clinics. 



ENCLOSURE THREE 



NEEDS OVERVIEW 



A. INTRODUCTION . This section will discuss in detail the importance of 
recognizing "medical need" and "healthy people." This enclosure will list reference 
material for further reading or investigation. After the population has been identified, 
health care planners should conduct an assessment of the populations' health care 
needs, simultaneous with or in the same general time period with the assessment of 
demand, discussed in the previous section. MacStravic, a leader in the field of health 
care planning states: "...the general purpose of health planning is to identify needs and 
to use them as goals in developing health action strategies" (p. 2). 

In the context of this document, health care need is defined as the services 
required to attain or maintain health. In the broader sense, health care need includes 
not only a set of health care services, but also the "the manpower, equipment, and 
facilities determined by organizations and communities to be requirements for 
maintaining and improving health" (MacStravic, p. 11). 

Support for needs assessment is an important component of health care planning. 
Military health planners have traditionally focused upon historical demand for care, as 
opposed to medical need. There is, however considerable support for needs 
assessment as a vital component of health care planning in the following areas: 

a. Operational Medicine--As a military health care system, emphasis must be 
placed upon the health services needed to maintain a ready fighting force during 
wartime and peacetime. 

b. Health Care Reform-Shift in emphasis from excellent health care for the few to 
basic minimum health care for the many will require a needs-focused, cost-effective 
health care system with greater emphasis upon preventive, primary and ambulatory 
care. 

c. DoD has been directed by Congress to develop a plan to implement the 
national objectives, Healthy People 2000. National Health Promotion and Disease 
Guidelines , published by the Department of Health and Human Services (DHHS) in 
September 1990. DoD has incorporated 181 of the 383 DHHS objectives into the DoD 
implementation plan. Health promotion is needs-focused. 



ENCLOSURE (3) 
25 Jan 94 



d. Accrediting and Regulating Agencies are focusing on need. The Joint 
Commission on Accreditation of Healthcare Organizations (JCAHO) 1994 Accreditation 
Manual for Hospitals standard LD.1.3 requires an organizational plan that "includes 
patient care services in response to identified patient needs...." Also, performance 
standards for comprehensive [community or catchment area] health planning from the 
Department of Health, Education and Welfare (DHEW) 1973 state: "The (health) plan 
should describe and analyze specific actions to meet area health needs... and delineate 
specific actions to meet area health need." Another DHEW reference states that "the 
planning of health facilities is based primarily on the identification of what health 
services are needed, where and in what volume" (MacStravic, p. 55). 

e. Total quality leadership (management) places emphasis on need. Juran, a 
leader in the total quality management movement, states that: Without exception, all 
published quality policies declare the intention to meet the needs of customers. The 
wording often includes identification of specific needs to be met--for example, that the 
company's products should provide customer satisfaction." (Emphasis in original. 
Juran, p. 186). He also advises planners to state customer needs in both quantitative 
and qualitative terms and points out that the goal of product performance relates to 
performance features in response to customer needs, such as promptness of service 
(p. 187). Juran also offers examples of Customer Need Flow Charts which are useful 
to planners (chap. 4). 



B. DIFFERENCE BETWEEN NEED AND DEMAND . Demand, for purposes Of this 
section, is met need. It is documented care provided to patients to meet specific 
health care needs identified by themselves and the providers of care. Demand is 
objective in that it is statistically quantifiable. Health care need, on the other hand, is 
more subjective and includes both met and unmet demand for health care services. 
Actual utilization is generally accepted as the equivalent of demand. 

Health needs cannot be measured,. ..determination of needs is the result of a 
subjective decision-making process rather than an objective measurement.... 
Ultimately, health needs are determined by an intellectual and political process which 
sets and modifies the goals and standards for health services; those goals and 
standards are then used to guide the development of the health system." (MacStravic, 
p. 8) 



25 Jan 94 



C. DETERMINING HEALTH CARE NEED . There are many inherent challenges 
associated with determining health care need. Determination of need is complicated 
by the facts that stated needs sometimes do not adequately reflect the real needs 
behind customer selections, customers have perceived needs that may not be born 
out by medical fact, and they also have regional and cultural needs, and those 
traceable to unintended use. An example of the latter is the frequent use of 
emergency departments by patients for non-emergent care. Customers' needs are 
also a moving target. New technology, market competition, social upheaval, and 
international conflicts are changing forces that create new customers' needs or 
change the priority given to existing ones. Because needs are not measurable, and 
often subjective, they are difficult to specify. 

Several types of health care needs have been defined in the literature. "As 
Donabedian describes it, health needs begin with a state of health, but are expressed 
in a need for services conceived in response to such states, and in the resources 
required to provide those services" (MacStravic, p. 5). From this perspective, there 
are three types of health care needs or conditions, which once determined, reflect 
services warranted by these needs or conditions. These conditions and related 
services are expressed as the types of health care needs that must be determined by 
planners: 

1. Health maintenance/promotion--need for basic health maintenance services 
generated by normal physical development (and the aging process); 

2. Acute morbidity-need for acute health services generated by incidence of 
specific episodes of disease or trauma; 

3. Chronic morbidity-need for chronic health services, generated by the 
prevalence of chronic disease and disability (MacStravic, pp. 58-59). 

Several methods and models have been developed to determine the health status 
of a population, determine the desired health status, and plan to fill the gap between 
current and desired health status. A modified version of MacStravic's model is 
detailed here for Navy Medical Department planners. (Juran's model is presented in 
attachment V). MacStravic's model emphasizes four techniques: population survey, 
demographic analysis, utilization assessment, and consensus reaching. These four 
techniques can be used in combination to assess the three different kinds of health 
care needs described above: 



25 Jan 94 



1 . Population survey - total population or sample members contacted to 
determine by interview or examination the actual health condition of each member. 
Some applicable methods follow from Juran's section on methods for discovering 
customers' needs (pp. 97-101). These include: 1) be a customer-use the product to 
acquire first-hand experience, or alternatively, through experiential training at the points 
of customer contact; 2) communicate with customers - generally customer-initiated 
contacts and is mainly a source of information about customer dissatisfactions; 3) 
market research - to provide answers to questions about product features, competitor 
products, etc. Patient satisfaction surveys are an example. DoD is developing a tri- 
service patient satisfaction survey and JCAHO standard LD. 1.3.1 states: "The 
organization gathers, assesses, and takes appropriate action on information that 
relates to the patient's satisfaction with services provided." 

After collecting the needs data, translate the needs into planners' language. 

2. Demographic analysis - estimates use the reported morbidity found in a 
study of one population and extrapolates them to another population on the basis of 
its demographic characteristics. Sources of morbidity data include Sherikon, Inc., 
which has compiled an extensive report of sources of morbidity data, methodologies 
for determining patient care needs and other planning methodologies. A detailed 
outline of the Sherikon report, in addition to selected pertinent excerpts is from the 
report are provided in Attachment III. Health. United States and Prevention Profile , 
produced yearly by DHHS, provides a very useful summary of health, morbidity, 
mortality, treatment and disease prevention trends. Advance Data is a periodical also 
produced by DHSS that reports on morbidity and treatment findings resulting from 
surveys conducted by the National Center for Health Statistics. The Department of 
Veterans Affairs has developed Health Services Inpatient and Outpatient Planning 
Models (See Attachment III for overview of the model.). 

3. Assessment of Utilization - Actual, Ideal and Expected Actual utilization 
(historical usage) is addressed as demand in the section V of this document. 
Measurement of the extent of services desired to maintain normal health in a 
population should be based on the demographic characteristics of the population 
itself. (MacStravic, pp. 16-17). Attachments IV and IV, respectively, list data banks 
and classification systems useful in gaining utilization statistics. 

Ideal utilization includes the number and types of services which ought to be 
utilized by a given population. It is useful only as a target of limit for planning because 
this information alone as a basis for allocation of resources would result in large 
numbers of under utilized resources and unacceptably high costs for care. It is 
equally inappropriate to plan resources on the basis of historical use without 
evaluating the appropriateness of the use. 



25 Jan 94 



Expected utilization is an estimation of the level of utilization that will result from 
analysis of actual and ideal usage checked by an evaluation of the appropriateness of 
the forecast based upon the expected amount of success in modifying behavior of 
consumers and providers as the result of direct intervention. 

The determination of future utilization of health services forecasts both the demand 
likely to occur with no intervention, and potential use likely to follow from a specific 
intervention.. ..In effect, three future conditions must be forecasted: what the future 
would be like if nothing is done to change it; what the future should be based on 
estimated conditions in the population; and what the future will be if action can be 
carried out to improve it. (MacStravic, pp. 108-09) 

4. Consensus-reaching. During this process, gather a group of concerned 
and qualified health professionals and ask them to agree on the extent of need in the 
population and what portion of the health care need is to be met by the health care 
system. To be most successful, the consensus-reaching should be based upon an 
extensive analysis of the data and information collected during the activities a., b., and 
c. above. Health professionals seeking to reach a consensus should be guided by the 
principle that: in effect, a service is needed when it is generally accepted that persons 
in a stated condition of health would significantly benefit from such a service. 

D. FORECASTING . MacStravic lists five categories of forecasting which are 
detailed in attachment II. 

E. INTERVENTION . Health promotion and preventive medicine are the medical 
tools of intervention directed towards reducing the incidence of disease and need for 
health care services. When projecting utilization, consideration must be given, not 
only to resources required for intervention efforts, but also the anticipated amount by 
which a successful intervention program will reduce the need for episodic and chronic 
health care and when the corresponding reductions in resources may be made. 
Preventive services can be applied at several stages. Primary preventive services 
relate to preventing the occurrence of disease or injury before it develops. Secondary 
services refer to the early detection and treatment of risk factors or preclinical disease 
which when altered or treated reverse, halt, or retard the progress of a condition. 
Tertiary services are those services and health maintenance activities undertaken after 
the onset of disease or occurrence of injury which can minimize complications and 
limit disability. 

An evolving trend is that "the annual 'checkup' is being abandoned in favor of a 
periodic health examination targeted at prevention, detection, and treating specific 
diseases or risk factors for difference age, sex, and high risk groups." (Sherikon, from 
Davis, et al., "Paying for Preventive Care: Moving the Debate Forward." Sherikon 
offers an example of Periodic Health Examination Packages. (See attachment III.) . 
Occupational Health is also an important part of maintaining a ready fighting force. 

25 Jan 94 



Physical fitness, health protection and disease ( prevention are essential elements of 
any occupational health program, as they are for the Department of the Navy. As the 
nation's largest employer, the federal government is concerned with the health of 
employees for human relations reasons and to avoid or minimize the problems 
associated with absenteeism, early retirement due to disability, and the decline in 
individual performance due to health problems. (Sherikon, SOW #3, Sect. II, p. 6) 

E. HEALTHY PEOPLE 2000 . Any comprehensive health care planning in the 
decade of the 1990s must consider the Healthy People 2000 initiative. It has three 
broad goals: 1) increase the Span of Healthy Life for Americans, i.e., increase the 
number of Americans who live long and healthy lives; 2) reduce the health disparities 
among Americans, i.e., improve the health of population groups that now are at 
highest risk of premature death, disease, and disability; and 3) achieve access to 
preventive health services for all Americans, and address the barriers to primary health 
care and clinical preventive services. Prevention, in the context of the Year 2000 
initiative, has three major components: health promotion, health protection, and 
preventive services. 

At the MTF level "local delivery of care and centralized monitoring, a significant 
portion of this initiative [Healthy People 2000] is the identification by the services and 
MTF commanders of baseline data to measure the actual effectiveness of these 
programs" (Sherikon, from Health Promotion and Disease Prevention for the Military 
Health Care System (Coordinated Care Program Concept Paper, 1991). Beneficiary 
education is another important part of Health Promotion. One of the important 
guidelines is the DoD/HA Coordinated Care Program Guidance Memorandum No. 6, 
Provider and Beneficiary Education. 

F. NEEDS DETERMINATION FOR THE NAVY POPULATION . Several initiatives 
are underway that will influence the provision of health care to Navy beneficiaries. 
Among these are the following: 1) Corporate measures of effectiveness (MOEs) being 
developed for Navy Medicine; 2) Health Affairs development of product lines, starting 
with an OB Product Line; 3) Health Affairs development of policies addressing health 
care for women as a top priority of the Department of Defense, including guidelines 
regarding adequate access and timely notification of mammography and Papanicolaou 
smear results, and the availability of obstetrical and gynecologic appointments for 
active duty women and epidural analgesia for normal vaginal deliveries (HA 
Memorandum 12 of Jan 93); 4) development of clinical practice guidelines (CPGs) 
based upon evidence-based methodology by the Committee on Disease Prevention 
and Health Promotion (MED-24B draft decision paper of 10 Nov 93); and 5) the 
managed care program, the success of which rests upon the management of care to 
meet the prevention and health care needs of patients. 



25 Jan 94 



G. IMPLICATIONS FOR STAFFING . Community (Catchment Area) Needs - On a 
community level, health needs become resource needs. An individual may require a 
visit to a doctor, an injection, an operation, or a stay in a hospital. The community 
needs a certain number of physicians and hospital facilities to meet individual needs. 
Planners should try to predict the numbers of units of service likely to be used for 
each type of health service and for the population which is identified as its 
constituency. The desired level of use for each service ought to be determined on the 
basis of the incidence and prevalence of situations accepted as calling for the use of 
given services. In general, such situations will fall into one of the three categories: 
health maintenance, acute morbidity, or chronic morbidity." {MacStravic, p. 15). 

Combine data derived from the needs analysis with demand data and review for 
appropriateness and feasibility, to include considerations of resource availability, policy 
considerations and modeling. The output of this effort is determination of what 
medical services are to be provided, to whom (customers), and by whom (staffing). 
The following references, provided in attachments VI and VII, respectively, offer two 
useful models to assist in determining staffing: "The Primary Care Model for Future 
Staffing Needs of the Navy," and "Comparison of Navy Hospital Physician With Health 
Maintenance Organization (HMO) Staffing For the Same Beneficiary Population." They 
will be discussed further in subsequent sections of this guide. 



25 Jan 94 



ENCLOSURE FOUR 



The Primary Care Model 
for Future Staffing Needs of the Navy 

In order to survive into the next decade, Navy medicine must take 
on priorities similar to those of national health reform while 
still maintaining the ability to meet its operational mission. 
While specifics of the civilian plan remain unconfirmed at present, 
there are some general trends that few would dispute as given. 

Primary Care Defined 

Primary care will be the focus and the controlling force behind 
delivery of high quality, cost effective health care. The term 
"primary care" has been defined several ways in the past. It is 
not a designated specialty as defined by any board certification 
process. It is a general term to describe an array of health care 
services distinguishable from secondary care (inpatient), tertiary 
(specialized inpatient) or specialty care (inpatient or outpatient 
care provided by physicians with more extensive training to 
patients with more severe illness/ injury) . 

Primary care is generally considered ambulatory. The term is used 
to describe the initial access point for patients to enter the 
health care system. The contact could be for routine, health 
maintenance services such as physical exams and immunizations; or 
for treatment of minor acute illness. A primary care provider 
would also provide ongoing care for chronic diseases. The point at 
which a patient transfers to a specialty care setting from the 
primary care one depends on the severity and co-morbidity of the 
illness, the training and experience of the primary care provider 
and the limitations of the facilities and technology in the primary 
care setting. 

All would agree that the term "primary care" includes at a minimum, 
Family Practice, General Internal Medicine and Pediatric services. 
In the Navy, primary care also includes GMO physicians who are 
graduate physicians who have not yet completed residency training 
programs that will further define them in a given specialty. 

Depending on program focus, others have added Obstetrics-Gynecology 
under the heading of primary care. Though this type of care may be 
the point of access for many women seeking ambulatory, minor acute 
care and it does have components of health maintenance in it 
(breast exams, Pap smears) , the specialty has too narrow of a focus 
on too narrow a segment of the population to be considered for our 
purposes. 

Ob-Gyn has really only been considered a primary care specialty in 
discussions of primary care shortages where an attempt is made to 
address some of the unmet demand (since they can provide some 
primary care services) . It also comes into play where patients are 
not otherwise assigned to a primary care provider and. need to find 
access into the system. 

When planning for comprehensive care comes into play, inclusion of 



Ob-Gyn specialists makes less sense. There is a relatively higher 
cost for these specialists to perform low complexity services 
(routine exams) that could be accomplished in the generalist 
primary care setting. Keeping the care at the Primary Care setting 
would result in more cost effective services with no decrement in 
quality. Moreover, it could be argued that the quality improves 
because one provider performs and monitors the status of all 
recommended exams and health preventive measures. 

Some studies of primary care staffing patterns have included 
Occupational Medicine physicians as primary care providers. While 
this may not be as significant for civilian health care reform, in 
terms of the Navy's priority for active duty care and the unique 
environment of the operational forces, occupational medicine may 
indeed be critical to maximizing appropriate resource use. In the 
active duty operational setting, as well as in civilian employee 
settings such as shipyards, many of the federal safety requirements 
(OSHA) require medical oversight. Because of the special nature of 
/the setting, more extensive use of occupational Medicine physicians 
may be called for. Maximum efficiency may dictate extensive use 
of Occupational Medicine technicians at the IDC training level to 
achieve a workable model. Unfortunately, the availability of such 
providers is probably as constrained as it is for other primary 
care specialties. 

Models for Future Staffing Needs 

In the past, DOD medical staffing studies have used historical 
workload as statistical forecasts of future need, or they have 
focused on current ways of delivering care in planning for future 
workload. Neither of these methods is meaningful anymore. 

If we accept that primary care controlled health care of defined 
populations is the future for us, then it is logical to look at the 
history of those types of systems, i.e., the HMOs. The premise is 
that primary care supports preventive care and controls access to 
high cost specialty care. The premise has been validated over many 
years of successful HMO operations that typically have both reduced 
medical care premiums and reductions in hospitalization rates. 

A recent literature review spanning 23 years of studies indicated 
that though there are some variation in numbers, the ratios of 
provider to patients by specialty are remarkably similar among the 
largest HMOs. Enclosure (1) is one study that examined these 
factors. Enclosure (2) contains data from other sources. It is 
useful to use several sources since one study may examine 
specialties in more detail than others. This information is 
important in helping us plan for future staffing based on 
population forecasts. 

The first study in enclosure (1) used both total and adjusted RAPS 
population data. Adjusted figures reflect factoring out of those 
eligible beneficiaries who did not use the direct care system, but 
used CHAMPUS instead. We can assume several major reasons, 
including: insufficient capacity at the MTF, barriers to access 



such as appointment times or geographical factors, and such 
intangibles as dissatisfaction with the direct care system. 
However, comprehensive health care planning for the future must 
include. all beneficiaries. Whether the care is provided in the 
direct care system or through a managed care network, we can expect 
to achieve more economies of scale if we maximize the market 
leverage of our large population groups and consolidate services 
where possible, whether it is in direct care or in an outside 
arrangement . 

Enclosure (3) represents the methodology used in Enclosure (1) as 
applied to the RAPS population data for 1999. The projections show 
only total population figures; BRAC III is included. it is 
painfully obvious that we have a severe shortage of primary care 
physicians, which is the same dilemma faced in civilian health care 
reform projections. We also share the mismatch and apparent over 
supply of specialists in some cases. 

Methods to Address the Primary Care Shortage 

Competition 

Competition for primary care providers will be acute. The military 
may, as it has been in the past, be at a disadvantage because of 
salary discrepancies for providers. However, the impact of the 
civilian health care reform shake down may actually improve 
recruiting of physicians. Civilian salaries have been reduced 
already because of Medicare coding reform and the proliferation of 
managed care plans demanding discounts. As a result, the salary 
tolerance levels have been altered. 

Moreover, in the past, military medicine has competed with the lure 
of the private practice setting that was both lucrative and very 
appealing because of its independent nature. Oversight of practice 
patterns and various forms of utilization management have reduced 
the independence factor and raised the hassle factor such that many 
physicians have thrown in the towel and assumed salaried positions. 

In the future we will be competing with entities that look very 
much like we do. Managed care organizations looking for 
contractual arrangements (PPO model) or in house salaried positions 
(staff HMO model) . We may also be competing with capitation based 
plans. 

Recruitment 

Every method of increasing primary care physicians has a time 
factor and a financial component associated with it. Recruitment 
goals must be realistic. What will it take to bring in a fully 
trained primary care physician from the civilian sector? What will 
the competition (other managed care plans) be offering him/her? We 
need to consider the differences in our unique environment that 
might appeal to physicians considering multiple options. 

Beyond that the Navy can attempt to offer training dollars to 
attract medical students as it has done in the past. Even more 



time and money must be factored in to reap the benefit of a new 
physician coming out of the "pipeline." Because of the high cost 
of medical education, which is not projected to decrease, 
subsidization of the education process is a strong incentive for 
many medical students. 

Re-training 

Other options need to be considered that require less time and 
money. One method frequently mentioned is "retraining" of 
specialists. It may be possible to retrain a physician in a period 
of one to two years with a hybrid program specifically designed for 
the military. Specialty board certification in Internal Medicine 
or Family Practice may not be possible, however, unless the 
critical shortage results in a redefinition of board certification 
requirements in the civilian sector. 

A more promising scenario that would prove more useful to both the 
military and civilian health care sectors would be the development 
of a new specialty of "Adult Primary care" specifically targeted 
for retrained physicians with its own board certification 
requirements. To reduce training requirements, the certification 
process could grant credit for previous training and experience. 
The new specialty would be for adult primary care only, thus 
negating the need for training in pediatrics and Ob-Gyn, as is 
currently required in Family Practice. The scope/depth of the 
training could be reduced somewhat to focus more on ambulatory 
rather than inpatient care, thus reducing requirements as in 
critical care management in Internal Medicine certification. 

Physician Substitution in Manpower Models 

The military has used non-physician health care providers for many 
years to supplement clinical care staffing needs in the system. 
Included in this group are Physician Assistants, Family Nurse 
Practitioners, Pediatric Nurse Practitioners, Ob-Gyn Nurse 
Practitioners, Nurse Midwifes, Nurse Anesthetists, Podiatrists and 
Independent Duty corpsmen. The numbers, distribution and 
recruitment efforts have varied depending on medical department 
priorities, size of the fleet and related needs, and the politics 
of those in charge at the time. The physician extenders have 
competed for precious few billets with other corps. Often, 
protection of corps turf and current politics took priority over 
concerns for the most cost effective and meaningful ways to meet 
the clinical needs of our beneficiaries. We can no longer afford 
to be so shortsighted. 

Independent Duty corpsmen 

If we start with a "bottom up" review of the health provider 
continuum, we begin with the provider with the shortest training 
line, that costs the least amount of money to employ and has the 
most restrictions on how they function. The IDC is trained to 
triage and treat minor acute illness/injury, recognize major 
problems requiring more specialized care and occasionally do all of 
this in complete isolation from the outside world, much less the 



medical world (as when the submarine is submerged and on patrol) . 

Any physician will tell you that a large portion of outpatient 
clinic visits consist of routine care. Whether it is annual 
physical exams of healthy people or treatment of a cold, the level 
of complexity is not high. The more highly trained a provider is, 
the more likely they are to be bored with a large number of these 
types of visits. If the system has the ability to control access 
into and direction through the health care system fas we do in the 
Navy) , then it can maximize use of low cost providers where 
appropriate. 

In addition, routine physicals while a major focus in the HMO model 
for maintenance of good health and early recognition of problems, 
is- often the least available service in the military system. 
Because of acute staff shortages historically, the medical care 
availability to dependents and retirees has frequently been limited 
to treatment of acute illness/ injury and follow up for chronic 
problems. Therefore, if the military system adopts the HMO/primary 
care model it must be able and willing to devote resources to the 
critical element of the HMO model;that is, health maintenance. If 
this does not occur or only happens partially, the result will be 
a huge investment in resources without the cost savings of an 
efficient and effective system designed. 

Expanding the role of the IDC would be a logical first step in 
altering the staffing picture. Since the IDC is already equipped 
to deal with minor illness/ injury, the next step would be to change 
the curriculum to include physical exams of normal, healthy people. 
The quality of that care could be further assured by restricting 
the patient population to adults between 18 and forty. This would 
factor out pediatrics and older adults who tend to have more 
serious illness and necessitate more referrals to higher levels of 
specialty care. Focusing on such a narrow segment of the 
population would produce low cost, highly effective health care 
providers who could assume care of a significant portion of the 
healthy population. 

The military health care system has some incredible latitude in 
program design because of its mission. ^There is increasing 
oversight by outside agencies (e.g., JCHO) , but we remain 
relatively free to do whatever is reasonable and necessary to 
accomplish the mission. Where else could you find the concept of 
an Independent Duty Corpsman (IDC) who functions as sole provider 
in an isolated environment such as a submarine? It is just this 
sort of creative strategy that we need to encourage, support and 
engender in our health care planners so that we may survive in the 
years to come. 

If a new dj^tribution and utilization for IDCs is undertaken, new 
manpower modeling must be developed. Since there are not 
comparable health care providers in the civilian sector, previous 
studies may not be available. Discussions with IDCs and physicians 
who have worked with IDCs would be helpful in developing models. It 



may be reasonable to start with the substitution models used for 
Physician Assistants and reduce the delegation factor further to 
reflect the lower training model. 

The other option is to define their use not in terms of a 
substitution for a physician, but rather as a substitution for 
certain elements of physician care. This may be the more 
appropriate model in a dependents clinic setting. In other words, 
the physicians would be the "team leader" for patient care, but 
would delegate physical exams, immunizations and history taking to 
the IDC. More experienced IDCs could function more independently 
as their situation dictates. 

Physician Assistants 

As we proceed up the continuum of health care, the next level is 
the Physician Assistant. The Physician Assistant' program was 
instituted 2 6 years ago in response to a shortage of physicians. 
As the specialty evolved, so did the applications for its use. 
While we find PAs in general and subspecialty Internal Medicine, we 
also now see Master's level training in general and orthopedic 
surgery and emergency medicine. These three specialties have 
typically been very difficult and expensive in terms of physician 
recruitment. The Navy has tremendous potential to reduce costs for 
the provision of those services with extensive use of lower cost 
PAs. 

While the literature contains information on substitution models 
for use of PAs in primary care, none was found for their use in 
surgical and emergency settings. In the primary care setting, it 
is estimated that between 60 and 90 percent of the care (depending 
on the study) can be delegated to a PA. A 1983 study by the Air 
Force (which may be the most comparable to Navy) concluded that the 
most efficient staffing ratio of PAs to physicians is 2 to l with 
maximization at a model of four physicians to eight to nine PAs. 
They concluded that this model reduced personnel costs 20% over an 
all physician staff. 

Unfortunately, the success of the PA program has driven up the 
salary levels in the civilian sector as well as the competition for 
jobs. The average starting salary is $37,000-44,000 and there are 
eight positions for every new graduate. The Navy must, therefore, 
gear up quickly to institute tuition reimbursement programs to get 
the supply to the required level. 

Family/Adult/Pediatric Nurse Practitioners 

Because Nurse Practitioners function in roles very much like that 
of the PA, many are confused as to the difference. Some would say 
that the two providers take different routes to arrive at the same 
point. While the basic certification of a PA requires a two year 
program (an associate degree is not first required in the civilian 
sector, but it is in the military) , Nurse Practitioners typically 
complete a Master's degree for certf ication and licensure. 

There are some very basic differences in training that will dictate 



the roles they are able to fill in military medicine. As the name 
implies, the Physician Assistant is truly a "physician extender." 
They are licensed only to function under the supervision (which 
will vary depending on the expertise of the PA) of a physician. 
Nurse Practitioners, on the other hand, are licensed as independent 
providers of care. Their focus is the health/wellness model of 
care and emphasis is placed on education and counseling. If the 
Navy is to truly adopt a HMO model of care, then resources to 
support health maintenance must be invested. The Nurse 
Practitioner would therefore, become central to that system. Not 
only are they a lower cost alternative to physicians, they are 
already fully trained in the "health" versus "illness" concept of 
medical care. 

The average starting salary for a hospital based Family Nurse 
Practitioner is about $35,000. A nurse with a BS degree can be 
licensed as a Nurse Practitioner with a Master's degree with two 
additional years of training. 

Variations to the Family Nurse Practitioner include the Pediatric 
Nurse Practitioner and the Adult Nurse Practitioner, both of whom 
have a more narrowly defined focus of training. 

To maximize use of the available options for delivery of health 
care, the Navy model should therefore be health maintenance driven 
with extensive use of Nurse Practitioners in concert with primary 
care physicians. If we assume a delegation factor of a 
conservative 60% then a rough estimate would be 3 Nurse 
Practitioners for every 2 physicians. Unfortunately, in most Navy 
clinics Nurse Practitioners exist only as one or two providers 
among many more physicians. A study should be conducted with Nurse 
Practitioners as it was with PAs to analyze the maximum 
substitution theory. 

Physician Assistants would seem to be better equipped to handle the 
acute care clinic or sick call setting in primary care, rather than 
as providers of routine health maintenance services. In addition, 
they could be used to extend the productivity of physicians in 
surgery and orthopedics. 

ob NP, CRNA, Nurse Midwife 

Military Specific Considerations for the Primary Care Model 

Although civilian experience and manpower models are useful for 
basic planning for the military health care system, special 
considerations do come into play. Some of these factors constrain 
us further, while others allow increased flexibility over our 
civilian counterparts. 

constraints 

Constraints include operational requirements that both take 
providers to sea for long periods and for temporary assignments. 
This affects the pool available for CONUS assignments. OCONUS MTFs 
have special needs because of geographical and medical isolation. 
Less tangible constraints include military specific daily 



obligations that affect productivity at both the individual and 
clinic level. 

If a comparison is made of the productivity between military and 
civilian physicians, the more tangible aspects would include 
ancillary, facility and management support. In the Navy, our 
physicians have little of any of the above. 

Because of billet limitations, we expect our physicians to share 
nursing support personnel with multiple others. A private practice 
physician would likely have one nurse whose sole job is to help 
him/her see patients, handle phone calls, keep supplies stocked and 
provide patient education/ counseling. That person might be an RN, 
LPN or CNA which would dictate the amount of work that could be 
delegated to them. The physician would also have partial FTEs to 
do the following: respond to requests for information from other 
physicians or insurance companies by reviewing medical records and 
making copies, fill out all the paperwork for signature, manage 
prescription refill requests, type dictated summaries of patient 
visits and file and follow up on insurance claims and patient 
billing. 

More importantly, a well run practice also has a professional 
manager (bachelor or master's level) who handles the daily 
multifaceted nature of the administrative burden thus allowing the 
physician to see patients more efficiently. Although, many of the 
administrative requirements of running a clinic/practice are not 
present in the MTF clinic, the fact remains that our physicians are 
not supported to maximize efficiency. 

A professional degree does not, however, assure a well prepared 
ambulatory manager. With increasing attention to ambulatory care, 
the military should consider changing the curriculum at the service 
schools to provide more practical training in clinic management to 
MSC officers, thereby freeing the NC to manage the clinical support 
side. 

The third critical element is facilities. In a private practice 
most physicians operate with 2-3 exam rooms, some operating quite 
well out of 5 at once, depending on the patient mix. Our Navy 
physicians are lucky to get one and sometimes are expected to share 
it. The exam room may be down the hall from the office and many 
more steps from the central nursing area and patient registration. 

Without benefit of nursing support, office facilities, a typed 
medical record and a clinic manager, it is no wonder that 
outpatient volume differs from those in the civilian environment. 
Then again, we are not able to accurately measure the volume 
difference since we have no measurement system. Without such a 
system, we cannot show providers what they have done as compared to 
the civilian system or what is expected of them 

Flexibility in the Military System 

There are some advantages to the military health care system that 



allows certain freedom in designing a model for the future. We 
have a degree of control over health care providers that definitely 
exceeds that of fee for service plans and perhaps somewhat more 
than even the HMO model. 

The military has always enjoyed special exemptions from state and 
federal laws that dictate delegation of clinical care to alternate 
providers, as is the case with IDCs. We also have the ability to 
shift providers from one location to another to respond to short, 
medium and long term manpower shortages. 

The military has the power to design and deliver whatever model of 
care it deems cost effective as long as it meets the basic 
provision of care dictate. That form can be in - house military 
providers (physician and non-physician) , in house contract or 
partnership providers or community civilian contract plans. 

other Differences for the Navy Population 

Other factors come into play in terms of both design and 
implementation of the primary care model. It must be pointed out 
that some of the cost effectiveness of the successful HMOs is based 
on their ability to screen out unhealthy (unprofitable) 
subscribers. While we cannot do that for the beneficiaries we 
serve, we also have a large portion of healthy active duty members 
that may serve to balance it out. 

Another demographic factor for the active duty population is a 
possible increased utilization for specialties such as orthopedics 
since they are an active group. Special focus on occupational 
stress factors, as well as related problems in family dynamics may 
produce an increase in psychiatric care needs. In addition, we do 
not limit the amount of psychiatric care as some civilian insurance 
plans do. 

Special environments such as nuclear submarines and aircraft 
dictate the addition of unique subspecialties such as radiation 
health, undersea medicine and flight surgery. Much of this active 
duty care is performed at the occupational point of service, 
thereby reducing demand in the hospital or branch clinic service 
sector. 

Because of added control of our active duty population we can 
achieve higher levels of compliance with recommended services such 
a immunizations. We may or may not be able to affect patient 
compliance rates with other regimens. 

Designing Measurement Tools 

Many have recognized that the MEPRS system has many limitations as 
a useful tool to measure productivity. Because it was designed as 
military in nature, it is by definition too narrow in focus and not 
relevant to the outside world. In order to support decision 
making, a new tool must be workable, meaningful and equate to 



civilian measures of productivity. 

As a test, data from the NH Charleston Third Party Billing system 
will be analyzed. Providers in the Internal Medicine Department 
fill out encounter forms on all patients (including active duty, 
dependents, retired and Medicare eligible) for all visits. The 
physicians then code the visit using CPT codes that include 
evaluation/ management codes and procedures such as 
echocardiograms. Collection of this data mirrors what an Internist 
in private practice records in order to submit claims to insurance 
companies. Therefore, we use the same data base to reflect the 
work accomplished. 

CPT codes have an added advantage in that the perceived value of 
the service (for reimbursement) is reflected in the Relative Value 
Units (RVU) associated with it. For example, the CPT code of 99202 
is for a Level 2 Office visit and has a higher RVU and a Level 1 
visit, 99201. We can then take the spread of frequencies of each 
code for each provider (and in aggregate for the clinic) and get a 
picture of the number and complexities of the services performed 
over a given period. 

Using the overhead portion of the MEPRS coding system (with 
physician salary factored out) , computing values for each CPT RVU 
and adding specific salary rates for each of the physicians we 
should get an idea of the cost of providing those services. We can 
then assign a value for the services for that clinic in that 
facility at the CPT code level. 

The same CPT coding system is the basis for CHAMPUS reimbursement. 
We can compare the CHAMPUS cost of purchasing that service in that 
geographical region with the cost of providing it in house. 
Complicating factors will include variances in volume based on 
unrelated factors, such as facility and support staff constraints; 
coding variances associated with training and personal motivation 
to code accurately. CPT codes drive revenues for civilian 
physicians and they are also the basis for charges of fraud if 
found to be upcoded in chart audits. 

Distribution of Resources 

If we develop a meaningful measurement system that allows us to 
compare the cost of providing in house services to the cost of 
purchasing those costs, we can then begin to analyze the data to 
determine the the most efficient distribtion of our resources. 
Each catchment area will have to be computed separately. 

In the past, we have consolidated our specialists into a few 
instituions to maximize their use and to account for more 
difficulty and cost in recruiting them. Under the primary care 
model, we know that specialty physicians will focus on the more 
complex care and delegate the routine to the primary care 
physicians. We know that under existing models it appears that the 
Navy is currently over staffed in some specialties. What we do not 



know is how the cost of the specialists will change over the next 
eight years. 

Will the vascular surgeon still be so highly compensated as a 
civilian that recruitment will be difficult? Or will the national 
health care reform movement also focusing on primary care decrease 
the demand for those services to the point that it drives those 
salaries down? Will the demand for civilian primary care providers 
be so extreme that they cannot be recuited easily? 

These are the critical questions. If, however, the staffing models 
are in place and the cost benefits analyses validated, we need^ only 
to plug in the figures to reach a "provide" or "buy" decision for 
each faciltiy. No often how much or how often the variables change 
we will have data to help make those decisions for today and for 
tomorrow {making certain assumptions and projections for the 
future) . 

The basis of the decision making must be geographically specific to 
account for differences in cost of living, cost of facilities and 
land, availabilitiy and cost of providers and competition for those 
providers. 

The data may show that the Navy can best fill its role by providing 
only primary care in house and purchasing all subspecialty care 
(inpatient and outpatient) . It may be global or it may vary 
dramatically by facility. We may see only a small portion of 
urgent primary care performed in the MTF with all the rest 
purchased while much of the existing specialty care stays in the 
MTF. Purchased care may be provided in MTFs or in civilian 
facilities. Purchased providers may work in our MTF or in their 
civilian setting. The Navcare concept may become the prime model 
that is adopted. 

Our traditional assumptions about staffing models may have to be 
altered to maximize resources. For example, we often assume that 
though the workload demands only one provider, we must provide two 
to allow for rotation of night coverage. We might also consider 
purchasing "pieces" of care, whereby, we contract with a civilian 
provider to do nothing other than provide after hours coverage. 
That service might occur in our facility or ours. Depending on how 
"hungry" that provider is, we might save a tremendous amount of 
money while rescuing a second military physician from terminal 
boredom and under utilization. 

If we truly embrace total quality leadership, we must consider all 
possibilities no matter how foreign they may be to the usual way of 
doing things. Personalities, corps competition and private agendas 
must be down played in favor of logical, thoughtful and 
analytically based and managment decisions. 



Annotated Bibliography 



Buchanan, J. and Hosek, S. Cost, Productivity and the Utilization 
of Physician Extenders in Air Force Primary Care Medicine clinics . 
Library of Congress, 1983. <W21.5 B918c 1983> 

At FY81 procurement levels a 2:1 staffing option 
decreases personnel cost 20% over an all MD staff; the 
most efficient being 4 MDs to 8-9 PAs 

Coleman, J.R. and Kaminsky, F.C. Ambulatory Care Systems , vol IV, 
Lexington Books, 1977. <W275 AA1 C57d 1977> 

Average MD to population ratios for 10 HMOs 



GP 


1:2544 


Gen Surg 


1:13,333 


Int Med 


1:2544 


Ob-Gyn 


1:10,526 


Peds 


1:6,666 


Primcare 


total 1:1 


Ortho 


1:28,571 


Urol 


1:52,631 


ENT 


1:38,461 


Derm 


1:38,461 


Allergy 


1:76,923 


Psych 


1:23,809 


Radiol 


1:27,777 


Anesth 


1:35,714 


Ophthal 


1:35,714 


Pathol 


1:66,666 



Kronick, Richard PhD et al. "Special Report: The Marketplace in 
Health Care Reform-The Demographic Limitations of Managed 
Competition." New England Journal of Medicine , Jan 14, 1993, p. 
148-52. 

LeRoy , L . The Cost Effectiveness of Nurse Practitioners. 
Washington, DC, Office of Technology Assessment, 1981, Case study 
no. 16. 

Loe, M.M., LT, MSC, USN, Specialty Advisor for Physician 
Assistants, Telephone Interview, 8 November 1993. 

Mulhausen, Robert MD and McGee, Jeanne PhD. "Physician Need: An 
Alternative Projection From a Study of Large, Prepaid Group 
Practices," JAMA , April 7, 1989, vol 261, no. 13, p. 1930-4. 

New England Journal of Medicine, vol. 314, no. 4, p. 217-22. 

Physician productivity in terms of ambulatory visits per 



FTE MD per year in 3 prepaid group models and in the 
GMENAC study: 

# Visits 

Peds FP Int Med 

Gmenac 5865 5520 3680 

Maxicare 6067 5464 3627 

MedCenters4734 3988 2903 

Harvard 4215 2840 

Perry, C. , CAPT, NC, USN, Assistant for Policy and Practice, Nurse 
Corps, BUMED. Personal Interview, 9 November 1993. 

Poirer-Elliot, E. "Cost Effectiveness of Non-Physician Health Care 
Professional." The Nurse Practitioner , 1984, 9:10, p. 54-6. 

Contains a cost effectiveness formula. Estimate' average 

MD salary less average NP salary plus cost of supervision 

(at 10% of MDs salary) to reach cost difference. Need to 

further factor in higher cost of MD education. States 

that 80-90% of services can be delegated, NP/MD 

substitution ratio of 0.63, NP/MD cost ratio of 0.38. If 

NP is 63% of work of MD at 38% of cost then savings to 

employ NP =24% (0.63 x 0.38) — these used old salary 

numbers . 

Record, J. C. , Final Report: Cost Effectiveness of Physician's 

Assistants in a Maximum Substitution Model: Phase II of a . Two Phase 

study, Washington, DC, Government Printing Office, Aug 75-Oct 76, 

(DHEW Publication no, (HRA) 67-1) . <T995> 

PAs reduce costs significantly. Can save 15% of its MD 
costs in primary care for adults if fully exploit 
substitution of PAs for MDs 

Record, J. C. Staffing Primary Care in 1990: Physician Replacement 
and Cost Savings. Springer Publishing Co., NY, 1981. <W1 SP685S V.6 
1981> 

Author is sr economist with Kaiser Permanente. Level of 
delegation 8 0% for adults, higher in peds. Substitution 
ratio of MDs to NPs= .50-. 75. Formula: 

MD= Ei 0V(t) fl-Di) fOVi/OVt^ 

Pmi 
NP= Ei ovt (di) fovi/ovt) 

Pni 

D= % of OVfoutpt visits) delegated 
MD= # of MDs required for a given level of D 
NP= # of NPs required for a given level of D 
0Vt= total volume of primary care OVs 
Pm= average MD productivity expressed as annual OVs 
Pn= average NP productivity expressed as annual OVs 
i= sector large or small practices with adult and peds care 
treated separately within each size group 



Ei= sum of all the sectors 

Delegation ratio 

Large practice Small Practice 

adult .50 .25 

peds .60 .30 

Most states limit MD to PA ratio to 1:2 
Savings 18-48% 

Rowley, W. , CAPT, MC, USN, Deputy Assistant Chief for Health Care 
Operations, BUMED, Personal Interview, 5 November 1993. 

Rowley, W. , CAPT, MC, USN, "Medical Care in the Year 2000: 
Predictions of Trends and Possible Health Policy Scenarios." Copy 
of Speech to MSC Quarterly Luncheon, 10 November 1993. 

Safriet, B. "Health Care Dollars and Regulatory Sense: The Role of 
Advanced Practice Nursing." Yale Journal on Regulation f Vol. 9, 
number 2, Summer 1992. 

Wennberg, David et al. "Equilibrium in U.S. Physician Supply." 
Health Affairs . Summer 1993, p. 90-102. 

Williams, C.R. , HMCM (SS) , USN, Chief, Hospital Corps, BUMED, 
Personal Interview, 8 November 1993. 



ENCLOSURE FIVE 



Comparison of Navy Hospital Physician Staffing With 

Health Maintenance Organization (HMO) Staffing 

For the Same Beneficiary Population 

SUMMARY : 

Large staff model health maintenance organizations (HMOs) are staffed with the limited number 
of physicians necessary to meet the needs of their enrolled LeneQciary populations. There is an emphasis 
on using primary care providers as "gate keepers" to manage patient care in an economical way. HMOs 
maintain financial health by being efficient and productive. Health care reform will promote managed 
competition among HMOs so it is a legitimate yardstick for measuring efficient staffing in Navy MTFs. 

Three studies over 23 years (End. (4)) show consistency in staffing among large staff model HMOs 
such as Kaiser and Group Health Cooperative of Puget Sound. The 1993 study by Kronick, et. el. (End. 
(4)) was used as the staffing standard for comparison in this study. 

Nayy hospitals cannot be directly compared to a civilian HMO for many reasons. MTFs have 
military-unique administrative requirements and operational obligations frequently pull staff away from 
patient care. Physical layout, equipment and staffing limitations prevent the efficiencies enjoyed in an 
HMO. Small facilities need enough physicians in specialties such as OB/GYN to provide 24-hour a day 
coverage even if the workload does not justify them. Military beneficiaries tend to "overuse" the MTF, 
especially the emergency medicine department. There is great demand for orthopedic services resulting in 
a several week backlog even though HMO standards would suggest an excess of orthopedists in MTFs. 

Even though the MTF and HMO systems are dissimilar, certain generalizations can be drawn from 
this comparison: 

• There appears to be an excess of surgical and some medical specialists while there is a significant 
deficiency in primary care physicians in the Navy. 

• The total number of physicians in the Navy for the beneficiary population actually served is significantly 
higher than what would be necessary in an HMO. This is partly accounted for by small MTFs which need 
a certain number for coverage and by the Navy's contingency requirements. However, it also suggests the 
Navy could improve efficiency in delivering patient care. 

ENCLOSURES : 

Enclosure (1) - Graphs comparing the differences in MTF and HMO staffing for different groups of 
MTFs. Some graphs are adjusted to reflect the number of beneficiaries actually using a MTF and some 
account for the entire eligible beneficiary population. The differences in Navy physicians compared to 
HMO standards are summed to give a the total excess or deficiency for each specialty group. 

Enclosure (2) - The data matrices graphed in enclosure (1). 

Enclosure (3) - The data for each MTF. 

Enclosure (4) - Civilian HMO staffing standards. 

9/19/93 MED-038 

NOTE: Due to the size of enclosures (1), (2) and (3), only portions of enclosure (1) and 
all of enclosure (4) are provided. If your are interested in seeing all of the enclosures 
contact MED-81. 



Physician Staffing Differences Between AH Navy 

Hospitals and a Staff Model MO for the Same 

Adjusted Beneficiary Population 









s 

fa 



600 



S wu [ 

| 500 
| 400 



300 



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Total catchment area beneficiaries corrected (reduced) for those not using MTFs for 
COIVUS MTFs only 



HI&-031 



Sources: FY-92 Navy Health Care Planning Matrix & NEJM 1993 328:148-152 



Encl.(l) 



Physician Staffing Differences Between All NAVY 
Hospitals and a Staff Model IHHO for the Same 
Total Catchment Area Beneficiaries 




* Includes all CONUS and OCOIVUS hospitals 

* All eligible beneficiaries in catchment area included 

Sources: FY-92 Na\y Health Care Planning Matrix & NEJM W93;328:148- 152 



HE0-03B 
End (I) 



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Differences in Physician Staffing 



■ 1 

e o 
9 9 



Primary Care 

OB/GYN 

General Surgery 

Orthopedics 

Emergency Medicine 

Anesthesia 

Radiology 

Psychiatry' 

Cardiology 

Urology 

Thoracic Surgery 

Neurosurgery 

Other Specialists 

Total Physicians 

BEDS 



-1 u 

9 9 
9 9 



9 
9 



9 
9 





■8 2! 

ST" 2 



Jr. * 



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Physician Staffing Differences Between All CON US 
nospitals and a Staff Model IIMO for the Same 
Total Catchment Area Beneficiaries 










S 


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b 


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5 


H 







H 





* All eligible beneficiaries in catchment area included 



Sources: FY-92 Na\y Health Care Planning Matrix & NEM 1993;328:148-152 



MEP-038 
End. (I) 



ESTIMATED NUMBER OF FULL-TIME-EQUIVALENT 

PHYSICIANS REQUIRED FOR 100,000 ENROLLEES 

IN THE "CLASSIC" STAFF MODEL 

HEALTH MAINTENANCE ORGANIZATION (HMO) 



1 PRACTICE BY 


1993 


1 1983 . 


3tudy 


1970 Study j 


SPECIALTY 


Study 


Mean # 


t Range 


Mean # 


i Range j 


TOTAL PHYSICIANS: 


117.9 


111.2 


98.6-119.7 


99.3 


83.3-101.7 1 


Primary Care/FP 


50* 


10.3 


2.2-17.5 


23.8 


11.9-43.5 


Pediatrics 


* 


14.9 


12.1-21.5 


17.1 


9.7-22.0 


Internal Medicine 


* 


24.8 


25.9-37.7 


27.3 


24.3-57.1 


Cardiology 


2.8 










Neurology 


+ 


1.5 


1.2-1.6 


0.9 


0.8-1.1 


Dermatology 


+ 


2.3 


0.6-2.9 


2.2 


1.0-3.0 


psychiatry 


3.8 


3.8 


1.9-4.6 


1.9 


0.7-2.1 


OB/GYK 


10.8 


10.7 


7.9-12.8 


10.3 


6.9-11.1 


General Surgery 


5.3 


5.8 


4.6-7.2 


8.1 


5.6-12.4 


Thoracic Surgery 


0.8 










Neurosurgery 


0.7 


0.6 


0.5-1.2 


0.9 


0.7-1.8 


Ophtha lmo logy 


+ 


2.9 


1.2-3.9 


2.8 


2.1-3.1 


Orthopedic Surgery 


5.0 


3.9 


2.9-4.4 


3.8 


2.9-4.0 


Oto laryngo lo gy 


+ 


2.3 


1.0-3.2 


2.2 


2.0-2.6 


Urology 


2.5 


2.2 


0.6-2.4 


1.6 


1.0-2.2 


Emergency Medicine 


4.8 


4.9 


0.3-10.0 


- 


- 


Anesthesiology 


5.0 


3.6 


"1.6-S.0 


2.3 


1.1-3.3 


Pathology 


+ 


1.7 


0.6-3.1 


1.3 


0.7-2.1 


Physical Medicine 




0.8 


0.3-1.3 


1.0 


0.8-1.0 


Radiology 


6.0 


4.4 


3.2-5.5 


3.4 


2.1-4.0 


Other Specialties 


20.3+ 








II 


Administration 




1.6 


0.8 T 3.4 


— 


_.. | 


TOTAL « HOSP. BEDS 


200 











• Primary care contains a mix of family practitioners, internist a and 
pediatricians 

+ Ophthalmology, otolaryngology, dermatology, pathology, hematology & 
oncology, neurology, gastroenterology, allergy & immunology, pulmonary 
medicine, nephrology, rheumatology, endocrinology, infectious diseases 
and plastic surgery included in "other specialties' 1 

Source of staffing standards: 

• 1993 Study data from Group Health Cooperative of Puget Sound and 4 
other large nonprofit staff model HMOs - NEJM 1993;328:148-152. 

• 1983 Study data from 7 large, Kaiser System HMOs - JAMA 1989;261:1930- 
1934. 

• 1970 Study data from 6 very large, closed-panel HMOs - JAMA 
1972;219:1621-1626. 



End. (4)